June 16, 2025 • 23 mins
✅ MSRA Deep Dive: Strawberry Naevus (Infantile Haemangioma)
A must-know vascular condition for exams and clinical practice, this episode breaks down the high-yield essentials of strawberry naevus, also known as infantile haemangioma. Perfect for your revision toolkit, especially if you're preparing for the MSRA.
🧠 Key Learning Points
📌 Definition
• A benign vascular tumour in infancy
• Often appears as a bright red, raised, soft lesion resembling a strawberry
• Typically emerges after birth and follows a distinct growth and regression timeline
📌 Natural History
• Proliferative phase: Rapid growth for the first 9 months
• Involution phase: Slow regression over years, often resolving by age 5–10
• Most lesions require no treatment and resolve spontaneously
📌 Pathophysiology
• Caused by abnormal endothelial cell proliferation
• Exact cause is unknown but may involve genetics and hormones
• Thought to result from vascular malformation during fetal development
⚠️ Red Flags & Complications
• Lesions on the eyelid → risk of amblyopia (lazy eye)
• Lesions near airway/oral cavity → risk of breathing or feeding issues
• Midline back lesions → consider spinal dysraphism (e.g., occult spina bifida)
• >5 cutaneous lesions → screen for internal haemangiomas (especially liver)
• Ulceration, bleeding, and secondary infection are possible
• Rare associations:
– Kasabach-Merritt syndrome (platelet trapping, coagulopathy)
– PHACE syndrome (neurocutaneous syndrome with large facial haemangiomas)
📈 Risk Factors
• Female infants (3:1 ratio)
• Prematurity and low birth weight
• Caucasian ethnicity
• Family history
• Multiple gestation (e.g., twins)
• Chorionic villus sampling (CVS) during pregnancy
🔍 Clinical Features
• Appears within the first few weeks of life
• Raised, bright or deep red, compressible
• Common sites: head and neck (60%), trunk, limbs
• ~20% of cases present with multiple lesions
🧪 Diagnosis
• Clinical diagnosis based on appearance and evolution
• Imaging (e.g., ultrasound, MRI) only if:
– Atypical or deep lesion
– Functional impairment
– >5 cutaneous lesions (→ screen liver)
• Biopsy avoided unless diagnosis is unclear due to bleeding risk
💊 Management
✔️ Watchful waiting
• First-line for uncomplicated lesions due to natural regression
✔️ Active treatment indicated when:
• Vision, breathing, or feeding is threatened
• Disfigurement is likely (e.g., nose, lip)
• Lesion is ulcerated, painful, or infected
• Lesion grows very rapidly or causes psychological distress
✔️ First-line treatment:
• Oral propranolol – beta-blocker that promotes involution
• Topical timolol – for small, superficial lesions
✔️ Other options:
• Intralesional corticosteroids, interferon-alpha (rare)
• Surgical
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
OK, let's unpack this. Welcome back to the Deep Dive.
Great to be here. Today we are plunging into a
topic you've asked for, especially if you're tackling
exams like the MSRA. Infantile hemangiomas may be
better known to some as strawberry Navy that's.
Right the strawberry nervous. Very common, very important for
exams. Our mission is simple but
crucial to extract the absolute most important high yield
(00:24):
information from the sources, structuring it like a targeted
audio revision session. Like a quick audio cram session
focusing on what you really needto recall.
Exactly. We're going to cover everything
from what these are to why they happen, what they look like,
and, you know, most importantly,how they're managed.
Let's do it. Let's jump right in with the
fundamental question, what is aninfantile Hemangioma or a
(00:45):
strawberry Nervous. OK, so at its heart, this is the
most common vascular tumour you'll see in infancy.
It's benign, meaning it's not cancerous, right?
Benign. And it's basically characterised
by by an abnormal growth of blood vessels.
And the common name Strawberry nyvis gives you a pretty clear
picture, right? What does it typically look
like? Exactly.
(01:05):
It's usually a raised lesion, often bright red or maybe deep
red, and when you touch it, it'stypically soft and compressible.
Soft and compressible. Yeah, it really does resemble a
strawberry, hence the name. It's quite descriptive.
Now, the Natural History of these is arguably the single
most important thing to understand because, well, it
(01:25):
dictates management, doesn't it?It doesn't just appear and stay
put. That's the absolute defining
feature, and it's crucial for revision.
You see, they often aren't present right at birth, though
about 1/3 can be. More commonly they appear within
the first few weeks, maybe starting as just a faint mark or
a flat spot. A subtle start, then.
(01:46):
Yeah. And then they enter a phase of
rapid growth. How rapid are we talking?
Typically this proliferative phase, the growth phase, is most
active until the infant is around, say, nine months old.
Right up to 9. This is when the lesion gets
bigger and becomes much more prominent.
But here's the critical part. The key takeaway?
After that, it spontaneously starts to regress.
(02:09):
It shrinks away on its own. Seriously.
Yes, it involutes. That's the term.
This regression phase is much slower than the growth phase,
though. It takes years.
Years, OK. Most of these lesions will have
resolved completely by the time a child is 10, maybe 12 years
old. So the key thing here is grow
fast early on. But then the vast majority just
(02:29):
disappear by themselves over time.
Precisely understanding that Natural History is fundamental.
That natural regression is definitely a game changer for
management, which we'll get to. But first, why do these happen?
What's the aetiology? Well, the exact cause isn't
fully pinned down, unfortunately, but the
underlying mechanism involves abnormal proliferation of blood
vessels during foetal development.
(02:50):
So something goes a bit wrong while the baby's developing.
Essentially yes. Think of it as a localised area
where the instructions for building tiny blood vessels went
a bit haywire, causing them to sort of multiply excessively in
one spot. It's like an over enthusiastic
construction crew building too many pipes in one corner of the
building. Is that a fair analogy?
(03:10):
That's a great analogy actually.A burst of building activity for
blood vessels. While the precise trigger is
unknown, genetic factors and hormones are thought to play
some role. Now you mentioned something
important earlier listed within aetiology in the sources the
potential for complications. This feels like linking the what
(03:31):
and how to the potential impact.That's exactly the connection we
need to make for clinical practise and exams.
While most hemangiomas are uncomplicated, maybe around 10%
can cause issues, and these often stem directly from where
they are located. Location, location location.
And the speed of that initial proliferation, we just talked.
About South location is a major red flag then.
(03:52):
Absolutely. Lesions in critical areas need
immediate attention. Think about the airway, the oral
cavity, or critically, the eye. The eye.
Why specifically? Well, a Hemangioma growing on an
upper eyelid, for instance, can actually obstruct vision during
that critical period of visual development.
So it could cause lasting sight problems.
Potentially yes, it could lead to amblyopia or lazy eye if it's
(04:15):
not managed early. Also, rapidly growing lesions on
the head or neck can, although rarely even interfere with
breathing. OK, that's serious.
Are there any other specific locations that should trigger
further investigation, like clues on the surface?
Yes, definitely. And this is a high yield point
for exams if you see a Hemangioma located over the
(04:35):
midline of the back. Midline back.
Got it. That should raise your suspicion
for an underlying spinal dysraphism.
OK. Hold on.
Spinal dysraphism? Can you just clarify what that
is simply? Sure.
Spinal dysraphism refers to a group of birth defects where the
spine or the spinal cord doesn'tclose properly during foetal
development. Think spina bifida spectrum,
essentially, right? So a Hemangioma in that specific
(04:59):
midline back location can be a surface marker, a kind of clue
that something might not be fully formed underneath.
It warrants investigation, maybean ultrasound or even an MRI of
the spine. Wow, OK, that's a really
important connection, A visible sign potentially pointing to a
hidden internal issue. Are there any other, perhaps
rarer conditions associated withhemangiomas that are worth
(05:20):
knowing for revision? Yes.
Though they are rare, 2 important associations come up.
First is Kasabach merit syndrome.
Kasabach merit. It's a very serious, potentially
life threatening condition. It's linked to large, often
complicated hemangiomas or otherspecific vascular tumours like
kaposiform hemangioendothelioma.It involves platelet trapping
(05:43):
within the lesion. Platelet trapping.
Yeah, but Lesion basically consumes platelets, leading to
very low platelet counts, thrombocytopenia and
consequently serious bleeding problems.
OK, very serious. And the other one.
The other is PHCE syndrome, PHACE.
And what is PHCE syndrome? Is that an acronym?
It is, yes. It's a neurocutaneous syndrome.
PACE stands for posterior fossa brain malformations, large
(06:07):
hemangiomas, typically facial ones, arterial anomalies,
cardiac defects, and eye abnormalities.
Whoa, that's a lot. It is so a large facial
Hemangioma might be the first clue that alerts you to this
complex multi system disorder. While rare, recognising these
associations is vital. It's fascinating here how a
(06:27):
seemingly straightforward skin lesion can sometimes be the tip
of the iceberg, really highlighting the importance of a
thorough assessment. OK, Moving on.
Are some babies more likely to get these than others?
What are the associated risk factors?
Well, the sources state there are no specific known risk
factors that absolutely guarantee development, but there
(06:48):
are several factors that are associated with a higher
incidence. OK, so.
Associations rather than direct causes.
Exactly. These are factors we just see
more often in babies who develophemangiomas.
And what are those associations?Who is more likely to get these?
Female gender is a notable one. They are significantly more
common in girls. How much more common?
About a three to one female ponderance.
SO3 girls for every boy, roughly.
(07:10):
Right. What else?
Prematurity and low birth weightare also strongly associated.
So small babies, early babies. Yes.
Other factors that pop up include a positive family
history. Runs in families sometimes.
It seems so also multiple gestation like twins or
triplets, and even a history of chorionic villa sampling or CVS
during pregnancy. Interesting.
(07:31):
Think of these as elements that might just flag a baby as
potentially being at a slightly higher statistical risk.
Interesting how those epidemiological factors overlap
quite a bit with what we consider risk factors.
Let's quickly revisit the path of Physiology.
How does that rapid proliferation actually happen at
the cellular level? You mentioned endothelial cells.
(07:52):
That's right. It's down to the endothelial
cells, the cells that line the inside of blood vessels in these
lesions. There's an abnormal and
excessive multiplication proliferation of these cells.
This is multiplied too fast. Exactly.
They form a densely packed area of vascular tissue.
It's this rapid cell division and growth that creates the bulk
of the Hemangioma in those initial months, the
proliferative phase. After that phase, the cells stop
(08:14):
multiplying quite so rapidly andthe process reverses in the
involution phase, leading to theshrinkage we talked about.
OK, understanding that proliferation and helps explain
the growth phase. Now shifting gears
significantly, what else could ared raised lesion on a baby be?
What are the crucial differential diagnosis we need
to consider? You know what else is on the
(08:35):
list? This is critical, absolutely
critical, for distinguishing thecommon benign infantile
Hemangioma from other things that might look similar but
behave very, very differently. Right.
Top of the list at. The top of the list, though
extremely rare in infants, is angiosarcoma.
Which is malignant cancerous. Precisely.
That's the one you absolutely don't want to miss.
(08:57):
Other differentials include things like arteriovenous
malformations or AV malformations, venous
malformations, and, importantly,congenital hemangiomas.
Congenital hemangiomas, you mentioned those.
What's the key difference again?Right.
The key difference is the timingand behaviour.
Infantile hemangiomas typically appear after birth, proliferate,
and then involute over years. Congenital hemangiomas, on the
(09:18):
other hand, are fully formed at birth.
They don't grow after birth and they typically either do not
involute at all, that's a NICH non involuting congenital
Hemangioma or they might involute very rapidly within the
first year or so. That's a riff, Ricey, rapidly
involuting congenital Hemangioma.
Or on the H and NICH. Got it.
(09:39):
That difference in Natural History present at birth.
No post birth growth is vital for distinguishing them.
Right. So if it's there, fully formed
at birth, and doesn't change or shrink slowly over years, it's
probably not the strawberry you're focusing on today.
What else might be on the differential list?
You might also consider a teratoma, particularly if it's
(09:59):
in a location where teratomas commonly occur, like the
sacrococcigeal area. Yeah.
And then there's diffuse neonatal hemangiomatosis that.
Sounds more widespread. It is.
It's characterised by having many hemangiomas, often small
ones scattered over the skin andsometimes involving internal
organs like the liver. This is a more serious
presentation that needs careful evaluation.
(10:19):
So the take away here for revision is while the classic
strawberry is common and usuallybenign, always pause think about
these other possibilities, especially the malignant 1
angiosarcoma and the congenital ones that behave differently.
Exactly. Understanding the differential
helps guide your next steps, whether it's watchful, waiting,
investigation, or management. OK.
(10:42):
Now let's zoom out a bit. How common are these generally?
What's the epidemiology look like?
Globally, infantile hemangiomas are estimated to occur in about
4 to 5% of newborns, so pretty common. 4 to 5%.
That's quite a few babies. It is.
The sources actually note that the prevalence specifically in
the UK is unknown, which is an interesting detail really.
(11:02):
OK, but that global figure givesyou a good sense of how
frequently you might encounter them in paediatric practise.
And are there demographic differences and prevalence?
You mentioned girls. Yes, there are clear
differences. As we touched on with risk
factors, they are notably more common in Caucasian babies.
More in Caucasian babies. Yeah, seen in about 5 to 10% in
(11:23):
that group compared to Afro, Caribbean and Asian children
where they are less common. Interesting.
And again, just to reinforce, the female preponderance is
strong about 3:00 to 1:00. Three girls to one boy.
And a higher incidence in premature infants and those with
low birth weight. These epidemiological points
really echo the risk factors we discussed.
OK. And so more common in Caucasian
(11:44):
babies, especially little girls who were born early or small.
Got it. Let's bring it back now to what
you actually see. What are the key clinical
features? Again, maybe building on our
initial description, how does itpresent?
OK, let's visualise it again. It's typically raised bright
red, sometimes a deeper red, soft, compressible to touch like
(12:05):
a strawberry. Exactly.
But the key clinical feature beyond the look is its
evolution. Remember, appears in the first
few weeks usually, though sometimes right at birth, then
that period of rapid growth until around nine months.
The proliferative phase. And then the slow gradual
regression over years, the involution phase, that whole
timeline is the clinical picture.
Where do we typically find them on the body?
(12:27):
The most common locations by farare the head and neck.
That accounts for about 60% of cases. 60% head and neck.
But honestly, they can appear anywhere on the body, trunk,
limbs, anywhere. It's also fairly common for
infants to have more than one lesion.
Oh, multiple. Yeah, about 20% of infants with
one will actually have multiple lesions.
(12:47):
And you mentioned a key number earlier regarding multiplicity,
a threshold. Yes, this is a detail worth
remembering. Clinically relevant if you find
more than 5 cutaneous strawberrynaive SO5 on the skin.
More than five. That increases the suspicion for
associated internal hemangiomas,particularly in the liver.
(13:08):
OK, so the number of lesions is another potential red flag, a
bit like location being important and symptoms.
Do they hurt or itch? Generally no.
Most simple cutaneous of angiomas are asymptomatic.
They don't usually cause pain oritching unless they say
ulcerate. The issues really arise, as
we've discussed, when they are very large, located in those
critical areas causing functional problems or if they
(13:30):
are internal. All right, we know what it is,
how it develops, what it looks like.
How do we confirm the diagnosis?Do we need fancy tests for every
single one? This is where that Natural
History pays off. Again, diagnosis is often
primarily clinical. Just by looking at it and
hearing the story. Pretty much yes, based on the
characteristic appearance, the strawberry look and the history
(13:51):
of how it's developed. Appeared after birth, grew
rapidly and experienced clinician can usually make the
diagnosis confidently without needing further tests.
So when do we need investigations then when do we
need imaging? Imaging like Doppler ultrasound
or perhaps an MRI is typically reserved for specific
situations. Firstly, if there's diagnostic
(14:11):
uncertainty, maybe it doesn't look quite classic, or you're
considering one of those differentials.
Or secondly, for complicated cases, if the lesion is very
large, if it's in a critical area like the airway or around
the eye, or if you suspect internal involvement based on
location or number, than imagingis recommended.
To see how deep it goes or what it's affecting.
Exactly to assess its extent andits impact on underlying
(14:35):
structures. What about biopsy?
You mentioned bleeding risk earlier.
Yeah, biopsy can be done, but should definitely be approached
with caution. Remember, these lesions are
highly vascular, lots of blood vessels, so there's a
significant risk of bleeding. It's usually not necessary for
diagnosing a classic uncomplicated infantile
Hemangioma reserved for really uncertain cases, usually after
(14:58):
imaging. OK.
And the rule about multiplicity investigation, you mentioned the
liver. That comes back to that point
about finding more than 5 cutaneous lesions.
In that scenario, guidelines often recommend considering an
ultrasound of the liver. Why the liver specifically?
Because the liver is the most common sight for internal or
visceral hemangiomas when they do occur alongside multiple skin
(15:20):
lesions, so it's a screening check.
OK. So clinical diagnosis is the
norm, imaging for complexity, uncertainty or suspected
internal involvement, cautious with biopsy and screen the liver
if there are lots of them, more than five, that makes sense.
That sums it up well. Now the big question management
if most disappear on their own, do we just watch and wait?
(15:43):
In the vast majority of cases, yes, absolutely.
The primary management strategy for uncomplicated infantile
hemangiomas is active observation or watchful waiting.
Let that spontaneous regression do its work.
So no active treatment needed for most.
For most lesions, especially small ones or those in non
(16:04):
critical locations, no treatmentis needed.
But there are scenarios where you do intervene.
You have to step in. Absolutely.
Intervention becomes necessary if the Hemangioma is causing or
threatening to cause functional impairment.
Functional impairment meaning what exactly?
You mean it's interfering with avital function like obstructing
vision, compromising the airway,breathing, interfering with
(16:26):
hearing, or making feeding difficult if it's around the
mouth? Also, intervention is considered
if it's causing significant disfigurement, especially on the
face, where it might lead to major scarring or psychological
distress later on. And timing matters here.
Yes, early intervention is key for those lesions affecting
critical functions like vision or breathing to prevent
permanent damage or complications.
(16:47):
So function and potential long term disfigurement are the main
triggers for treatment. What's the go to treatment when
you do need to act, especially for those still in that rapid
growth phase? The preferred treatment now,
based on current guidance like NICE, CKS and general NHS
practise, is Propranolol. Propranolol.
(17:07):
That's a beta blocker right? Usually used for heart
conditions. It is yes.
Oral Propranolol is the established first line treatment
for problematic proliferating infantile Hemangioma.
How does a beta blocker work fora Hemangioma?
That seems counterintuitive. It's actually fascinating.
The exact mechanism isn't fully understood, but it's thought to
work in a few ways. It seems to cause
(17:27):
vasoconstriction, meaning it narrows the blood vessels within
the Hemangioma. Reduces blood flow.
Reduces blood flow, yes. It might also decrease the
production of growth factors that stimulate vessel growth and
potentially even induce apoptosis, or programmed cell
death in those proliferating endothelial cells.
Wow. OK.
So it tackles it from multiple angles potentially.
(17:49):
And how is it used? Is it a long course?
Typically, oral Propranolol is started during the proliferative
phase, usually in infancy, and continued for several months,
often until around one year of age or until growth has clearly
stopped and regression is underway.
And are there other options besides oral?
Yes. For smaller, thinner or more
superficial lesions, topical timolol is often used.
(18:10):
Timol is also a beta blocker applied directly to the skin as
drops or gel. It can be quite effective for
the right type of lesion. So Propranolol oral or timolol
topical are the main players when intervention is needed.
What kind of specific situationsreally warrant this beta blocker
treatment? Think back to the complications
we discussed. Propranolol would be indicated
(18:31):
for lesions causing or threatening vision loss like
large eyelid hemangiomas, airwayobstruction, feeding
difficulties, large facial lesions causing disfigurement or
ulcerated hemangiomas which can be painful and bleed or get
infected. Also rarely for very large
lesions causing heart stream. OK, let's run a quick scenario
then, like an MSRA question might pose.
(18:52):
Imagine you have a three month old infant presenting with a
rapidly enlarging bright red lesion right on the tip of their
nose. It's growing quickly.
Based on what we've just discussed, what's the most
likely next step in management? OK.
So three month old rapid growth tip of the nose, that's a
cosmetically sensitive area prone to disfigurement and it's
clearly in the proliferative phase.
(19:14):
Functional impairment is an immediate, but the risk of
significant long term cosmetic issues is high.
Therefore, the most likely next step according to guidelines
would be to initiate treatment to halt proliferation and induce
regression. The preferred first line
treatment would be oral procranolol.
Perfect example of linking the features, location, age, growth
(19:34):
phase to the likely management strategy.
Are there any other treatment options, maybe less common these
days? Yes, although they are used much
less frequently now that beta blockers are established as
first line intralesional corticosteroids.
Injecting steroids directly intothe lesion can sometimes be used
to slow proliferation, particularly maybe for smaller
localised lesions or if beta blockers aren't suitable.
(19:57):
Interferon Alpha has been used historically and very specific,
often severe or life threateningcases, but it has significant
side effects. And surgical excision is an
option too. They're cutting it out.
Yes, but it requires careful consideration due to the
vascularity and bleeding risk. It's usually reserved for
smaller lesions that are easily removable, or sometimes for
addressing residual tissue or scarring after involution has
(20:20):
occurred naturally or with treatment.
For very large or life threatening lesions, a
multidisciplinary approach involving paediatricians,
dermatologists, surgeons and maybe interventional
radiologists for procedures likeembolization might be needed.
So Propranolol is really the headline treatment for
problematic cases, but other tools exist in the toolbox for
specific situations. Now, looking long term, what's
(20:43):
the prognosis like for these babies generally?
Generally speaking, the prognosis is excellent, really
very good. It's good to hear.
As we've emphasised, the vast majority regress spontaneously
without causing any long term problems or complications.
That Natural History is key. And by what age are they
typically gone by? You mentioned 1012 earlier.
Yeah, Complete resolution usually occurs by age 5 to 10
(21:06):
years, sometimes stretching to 12.
The bulk of the regression oftenhappens by school age.
Does the skin always look completely normal afterwards or
can you sometimes tell somethingwas there?
Not always absolutely perfectly normal, no.
While often the cosmetic result is very good, especially for
smaller ones, some cases might be left with minor lingering
(21:27):
effects, like what you might seesome residual telangitasias,
those are tiny widened blood vessels on the surface.
Or there might be slight textural changes in the skin,
maybe a bit of wrinkling, atrophy or slight discoloration
where the Hemangioma used to be.But overall, the functional
outcome is usually excellent andthe cosmetic outcome is
typically very favourable, especially compared to how it
(21:48):
looked during the growth phase. That's definitely reassuring
news for parents. Finally, let's just quickly
recap the potential complications, reinforcing why
we monitor them closely and sometimes intervene.
Right, So important to remember most lesions do not 'cause
complications, but the potentialones we've touched on include
ulceration. Where the skin breaks down.
Exactly, that can be quite painful, prone to bleeding and
(22:12):
can get infected. Bleeding itself can happen,
though often it's minor, maybe just oozing.
Unless the lesion is traumatisedor it's part of a syndrome like
Kassebach Merit and infection ofthe lesion itself is possible,
especially if it ulcerates. OK.
And linking back to management triggers.
Exactly. The most significant
complications, the ones that usually drive treatment
(22:33):
decisions, arise from that functional impairment caused by
the lesion's location and size, obstructing vision, blocking the
airway, interfering with feeding, etcetera.
That's why regular monitoring bya healthcare professional is
crucial, especially during infancy, to catch these issues
early and intervene appropriately with treatments
like Propranolol if needed. OK, brilliant.
We've just done a really high yield deep dive into infantile
(22:57):
Hemangioma, also known as strawberry and Ivis.
We've covered its definition, that fascinating Natural History
of growth and shrinkage, potential causes, and those
important associations like PACEand CASABAC merit the red flags
like location and number. The risk factors, what's
happening at the cellular level,what else it could be, those
differentials, how common it is and who tends to get it, what it
(23:20):
looks like clinically and its growth pattern.
How we investigate it when needed.
The crucial management approach focusing on watchful weighting
but using Propranolol for problematic cases and finishing
with the generally excellent prognosis alongside those
potential complications to watchfor.
It's a lot packed in, but hopefully focusing on these core
concepts, especially the NaturalHistory and the indications for
(23:41):
treatment, is really key for mastering this topic for
revision. Absolutely.
For more free MSRA revision resources, remember to visit
freesra.com and for the full Premium Revision Toolkit, head
over to pastms-r.com. Keep up the great work with your
revision. Keep reviewing and best of luck
with your studies.
OK, let's unpack this. Welcome back to the Deep Dive.
Great to be here. Today we are plunging into a
topic you've asked for, especially if you're tackling
exams like the MSRA. Infantile hemangiomas may be
better known to some as strawberry Navy that's.
Right the strawberry nervous. Very common, very important for
exams. Our mission is simple but
crucial to extract the absolute most important high yield
(00:24):
information from the sources, structuring it like a targeted
audio revision session. Like a quick audio cram session
focusing on what you really needto recall.
Exactly. We're going to cover everything
from what these are to why they happen, what they look like,
and, you know, most importantly,how they're managed.
Let's do it. Let's jump right in with the
fundamental question, what is aninfantile Hemangioma or a
(00:45):
strawberry Nervous. OK, so at its heart, this is the
most common vascular tumour you'll see in infancy.
It's benign, meaning it's not cancerous, right?
Benign. And it's basically characterised
by by an abnormal growth of blood vessels.
And the common name Strawberry nyvis gives you a pretty clear
picture, right? What does it typically look
like? Exactly.
(01:05):
It's usually a raised lesion, often bright red or maybe deep
red, and when you touch it, it'stypically soft and compressible.
Soft and compressible. Yeah, it really does resemble a
strawberry, hence the name. It's quite descriptive.
Now, the Natural History of these is arguably the single
most important thing to understand because, well, it
(01:25):
dictates management, doesn't it?It doesn't just appear and stay
put. That's the absolute defining
feature, and it's crucial for revision.
You see, they often aren't present right at birth, though
about 1/3 can be. More commonly they appear within
the first few weeks, maybe starting as just a faint mark or
a flat spot. A subtle start, then.
(01:46):
Yeah. And then they enter a phase of
rapid growth. How rapid are we talking?
Typically this proliferative phase, the growth phase, is most
active until the infant is around, say, nine months old.
Right up to 9. This is when the lesion gets
bigger and becomes much more prominent.
But here's the critical part. The key takeaway?
After that, it spontaneously starts to regress.
(02:09):
It shrinks away on its own. Seriously.
Yes, it involutes. That's the term.
This regression phase is much slower than the growth phase,
though. It takes years.
Years, OK. Most of these lesions will have
resolved completely by the time a child is 10, maybe 12 years
old. So the key thing here is grow
fast early on. But then the vast majority just
(02:29):
disappear by themselves over time.
Precisely understanding that Natural History is fundamental.
That natural regression is definitely a game changer for
management, which we'll get to. But first, why do these happen?
What's the aetiology? Well, the exact cause isn't
fully pinned down, unfortunately, but the
underlying mechanism involves abnormal proliferation of blood
vessels during foetal development.
(02:50):
So something goes a bit wrong while the baby's developing.
Essentially yes. Think of it as a localised area
where the instructions for building tiny blood vessels went
a bit haywire, causing them to sort of multiply excessively in
one spot. It's like an over enthusiastic
construction crew building too many pipes in one corner of the
building. Is that a fair analogy?
(03:10):
That's a great analogy actually.A burst of building activity for
blood vessels. While the precise trigger is
unknown, genetic factors and hormones are thought to play
some role. Now you mentioned something
important earlier listed within aetiology in the sources the
potential for complications. This feels like linking the what
(03:31):
and how to the potential impact.That's exactly the connection we
need to make for clinical practise and exams.
While most hemangiomas are uncomplicated, maybe around 10%
can cause issues, and these often stem directly from where
they are located. Location, location location.
And the speed of that initial proliferation, we just talked.
About South location is a major red flag then.
(03:52):
Absolutely. Lesions in critical areas need
immediate attention. Think about the airway, the oral
cavity, or critically, the eye. The eye.
Why specifically? Well, a Hemangioma growing on an
upper eyelid, for instance, can actually obstruct vision during
that critical period of visual development.
So it could cause lasting sight problems.
Potentially yes, it could lead to amblyopia or lazy eye if it's
(04:15):
not managed early. Also, rapidly growing lesions on
the head or neck can, although rarely even interfere with
breathing. OK, that's serious.
Are there any other specific locations that should trigger
further investigation, like clues on the surface?
Yes, definitely. And this is a high yield point
for exams if you see a Hemangioma located over the
(04:35):
midline of the back. Midline back.
Got it. That should raise your suspicion
for an underlying spinal dysraphism.
OK. Hold on.
Spinal dysraphism? Can you just clarify what that
is simply? Sure.
Spinal dysraphism refers to a group of birth defects where the
spine or the spinal cord doesn'tclose properly during foetal
development. Think spina bifida spectrum,
essentially, right? So a Hemangioma in that specific
(04:59):
midline back location can be a surface marker, a kind of clue
that something might not be fully formed underneath.
It warrants investigation, maybean ultrasound or even an MRI of
the spine. Wow, OK, that's a really
important connection, A visible sign potentially pointing to a
hidden internal issue. Are there any other, perhaps
rarer conditions associated withhemangiomas that are worth
(05:20):
knowing for revision? Yes.
Though they are rare, 2 important associations come up.
First is Kasabach merit syndrome.
Kasabach merit. It's a very serious, potentially
life threatening condition. It's linked to large, often
complicated hemangiomas or otherspecific vascular tumours like
kaposiform hemangioendothelioma.It involves platelet trapping
(05:43):
within the lesion. Platelet trapping.
Yeah, but Lesion basically consumes platelets, leading to
very low platelet counts, thrombocytopenia and
consequently serious bleeding problems.
OK, very serious. And the other one.
The other is PHCE syndrome, PHACE.
And what is PHCE syndrome? Is that an acronym?
It is, yes. It's a neurocutaneous syndrome.
PACE stands for posterior fossa brain malformations, large
(06:07):
hemangiomas, typically facial ones, arterial anomalies,
cardiac defects, and eye abnormalities.
Whoa, that's a lot. It is so a large facial
Hemangioma might be the first clue that alerts you to this
complex multi system disorder. While rare, recognising these
associations is vital. It's fascinating here how a
(06:27):
seemingly straightforward skin lesion can sometimes be the tip
of the iceberg, really highlighting the importance of a
thorough assessment. OK, Moving on.
Are some babies more likely to get these than others?
What are the associated risk factors?
Well, the sources state there are no specific known risk
factors that absolutely guarantee development, but there
(06:48):
are several factors that are associated with a higher
incidence. OK, so.
Associations rather than direct causes.
Exactly. These are factors we just see
more often in babies who develophemangiomas.
And what are those associations?Who is more likely to get these?
Female gender is a notable one. They are significantly more
common in girls. How much more common?
About a three to one female ponderance.
SO3 girls for every boy, roughly.
(07:10):
Right. What else?
Prematurity and low birth weightare also strongly associated.
So small babies, early babies. Yes.
Other factors that pop up include a positive family
history. Runs in families sometimes.
It seems so also multiple gestation like twins or
triplets, and even a history of chorionic villa sampling or CVS
during pregnancy. Interesting.
(07:31):
Think of these as elements that might just flag a baby as
potentially being at a slightly higher statistical risk.
Interesting how those epidemiological factors overlap
quite a bit with what we consider risk factors.
Let's quickly revisit the path of Physiology.
How does that rapid proliferation actually happen at
the cellular level? You mentioned endothelial cells.
(07:52):
That's right. It's down to the endothelial
cells, the cells that line the inside of blood vessels in these
lesions. There's an abnormal and
excessive multiplication proliferation of these cells.
This is multiplied too fast. Exactly.
They form a densely packed area of vascular tissue.
It's this rapid cell division and growth that creates the bulk
of the Hemangioma in those initial months, the
proliferative phase. After that phase, the cells stop
(08:14):
multiplying quite so rapidly andthe process reverses in the
involution phase, leading to theshrinkage we talked about.
OK, understanding that proliferation and helps explain
the growth phase. Now shifting gears
significantly, what else could ared raised lesion on a baby be?
What are the crucial differential diagnosis we need
to consider? You know what else is on the
(08:35):
list? This is critical, absolutely
critical, for distinguishing thecommon benign infantile
Hemangioma from other things that might look similar but
behave very, very differently. Right.
Top of the list at. The top of the list, though
extremely rare in infants, is angiosarcoma.
Which is malignant cancerous. Precisely.
That's the one you absolutely don't want to miss.
(08:57):
Other differentials include things like arteriovenous
malformations or AV malformations, venous
malformations, and, importantly,congenital hemangiomas.
Congenital hemangiomas, you mentioned those.
What's the key difference again?Right.
The key difference is the timingand behaviour.
Infantile hemangiomas typically appear after birth, proliferate,
and then involute over years. Congenital hemangiomas, on the
(09:18):
other hand, are fully formed at birth.
They don't grow after birth and they typically either do not
involute at all, that's a NICH non involuting congenital
Hemangioma or they might involute very rapidly within the
first year or so. That's a riff, Ricey, rapidly
involuting congenital Hemangioma.
Or on the H and NICH. Got it.
(09:39):
That difference in Natural History present at birth.
No post birth growth is vital for distinguishing them.
Right. So if it's there, fully formed
at birth, and doesn't change or shrink slowly over years, it's
probably not the strawberry you're focusing on today.
What else might be on the differential list?
You might also consider a teratoma, particularly if it's
(09:59):
in a location where teratomas commonly occur, like the
sacrococcigeal area. Yeah.
And then there's diffuse neonatal hemangiomatosis that.
Sounds more widespread. It is.
It's characterised by having many hemangiomas, often small
ones scattered over the skin andsometimes involving internal
organs like the liver. This is a more serious
presentation that needs careful evaluation.
(10:19):
So the take away here for revision is while the classic
strawberry is common and usuallybenign, always pause think about
these other possibilities, especially the malignant 1
angiosarcoma and the congenital ones that behave differently.
Exactly. Understanding the differential
helps guide your next steps, whether it's watchful, waiting,
investigation, or management. OK.
(10:42):
Now let's zoom out a bit. How common are these generally?
What's the epidemiology look like?
Globally, infantile hemangiomas are estimated to occur in about
4 to 5% of newborns, so pretty common. 4 to 5%.
That's quite a few babies. It is.
The sources actually note that the prevalence specifically in
the UK is unknown, which is an interesting detail really.
(11:02):
OK, but that global figure givesyou a good sense of how
frequently you might encounter them in paediatric practise.
And are there demographic differences and prevalence?
You mentioned girls. Yes, there are clear
differences. As we touched on with risk
factors, they are notably more common in Caucasian babies.
More in Caucasian babies. Yeah, seen in about 5 to 10% in
(11:23):
that group compared to Afro, Caribbean and Asian children
where they are less common. Interesting.
And again, just to reinforce, the female preponderance is
strong about 3:00 to 1:00. Three girls to one boy.
And a higher incidence in premature infants and those with
low birth weight. These epidemiological points
really echo the risk factors we discussed.
OK. And so more common in Caucasian
(11:44):
babies, especially little girls who were born early or small.
Got it. Let's bring it back now to what
you actually see. What are the key clinical
features? Again, maybe building on our
initial description, how does itpresent?
OK, let's visualise it again. It's typically raised bright
red, sometimes a deeper red, soft, compressible to touch like
(12:05):
a strawberry. Exactly.
But the key clinical feature beyond the look is its
evolution. Remember, appears in the first
few weeks usually, though sometimes right at birth, then
that period of rapid growth until around nine months.
The proliferative phase. And then the slow gradual
regression over years, the involution phase, that whole
timeline is the clinical picture.
Where do we typically find them on the body?
(12:27):
The most common locations by farare the head and neck.
That accounts for about 60% of cases. 60% head and neck.
But honestly, they can appear anywhere on the body, trunk,
limbs, anywhere. It's also fairly common for
infants to have more than one lesion.
Oh, multiple. Yeah, about 20% of infants with
one will actually have multiple lesions.
(12:47):
And you mentioned a key number earlier regarding multiplicity,
a threshold. Yes, this is a detail worth
remembering. Clinically relevant if you find
more than 5 cutaneous strawberrynaive SO5 on the skin.
More than five. That increases the suspicion for
associated internal hemangiomas,particularly in the liver.
(13:08):
OK, so the number of lesions is another potential red flag, a
bit like location being important and symptoms.
Do they hurt or itch? Generally no.
Most simple cutaneous of angiomas are asymptomatic.
They don't usually cause pain oritching unless they say
ulcerate. The issues really arise, as
we've discussed, when they are very large, located in those
critical areas causing functional problems or if they
(13:30):
are internal. All right, we know what it is,
how it develops, what it looks like.
How do we confirm the diagnosis?Do we need fancy tests for every
single one? This is where that Natural
History pays off. Again, diagnosis is often
primarily clinical. Just by looking at it and
hearing the story. Pretty much yes, based on the
characteristic appearance, the strawberry look and the history
(13:51):
of how it's developed. Appeared after birth, grew
rapidly and experienced clinician can usually make the
diagnosis confidently without needing further tests.
So when do we need investigations then when do we
need imaging? Imaging like Doppler ultrasound
or perhaps an MRI is typically reserved for specific
situations. Firstly, if there's diagnostic
(14:11):
uncertainty, maybe it doesn't look quite classic, or you're
considering one of those differentials.
Or secondly, for complicated cases, if the lesion is very
large, if it's in a critical area like the airway or around
the eye, or if you suspect internal involvement based on
location or number, than imagingis recommended.
To see how deep it goes or what it's affecting.
Exactly to assess its extent andits impact on underlying
(14:35):
structures. What about biopsy?
You mentioned bleeding risk earlier.
Yeah, biopsy can be done, but should definitely be approached
with caution. Remember, these lesions are
highly vascular, lots of blood vessels, so there's a
significant risk of bleeding. It's usually not necessary for
diagnosing a classic uncomplicated infantile
Hemangioma reserved for really uncertain cases, usually after
(14:58):
imaging. OK.
And the rule about multiplicity investigation, you mentioned the
liver. That comes back to that point
about finding more than 5 cutaneous lesions.
In that scenario, guidelines often recommend considering an
ultrasound of the liver. Why the liver specifically?
Because the liver is the most common sight for internal or
visceral hemangiomas when they do occur alongside multiple skin
(15:20):
lesions, so it's a screening check.
OK. So clinical diagnosis is the
norm, imaging for complexity, uncertainty or suspected
internal involvement, cautious with biopsy and screen the liver
if there are lots of them, more than five, that makes sense.
That sums it up well. Now the big question management
if most disappear on their own, do we just watch and wait?
(15:43):
In the vast majority of cases, yes, absolutely.
The primary management strategy for uncomplicated infantile
hemangiomas is active observation or watchful waiting.
Let that spontaneous regression do its work.
So no active treatment needed for most.
For most lesions, especially small ones or those in non
(16:04):
critical locations, no treatmentis needed.
But there are scenarios where you do intervene.
You have to step in. Absolutely.
Intervention becomes necessary if the Hemangioma is causing or
threatening to cause functional impairment.
Functional impairment meaning what exactly?
You mean it's interfering with avital function like obstructing
vision, compromising the airway,breathing, interfering with
(16:26):
hearing, or making feeding difficult if it's around the
mouth? Also, intervention is considered
if it's causing significant disfigurement, especially on the
face, where it might lead to major scarring or psychological
distress later on. And timing matters here.
Yes, early intervention is key for those lesions affecting
critical functions like vision or breathing to prevent
permanent damage or complications.
(16:47):
So function and potential long term disfigurement are the main
triggers for treatment. What's the go to treatment when
you do need to act, especially for those still in that rapid
growth phase? The preferred treatment now,
based on current guidance like NICE, CKS and general NHS
practise, is Propranolol. Propranolol.
(17:07):
That's a beta blocker right? Usually used for heart
conditions. It is yes.
Oral Propranolol is the established first line treatment
for problematic proliferating infantile Hemangioma.
How does a beta blocker work fora Hemangioma?
That seems counterintuitive. It's actually fascinating.
The exact mechanism isn't fully understood, but it's thought to
work in a few ways. It seems to cause
(17:27):
vasoconstriction, meaning it narrows the blood vessels within
the Hemangioma. Reduces blood flow.
Reduces blood flow, yes. It might also decrease the
production of growth factors that stimulate vessel growth and
potentially even induce apoptosis, or programmed cell
death in those proliferating endothelial cells.
Wow. OK.
So it tackles it from multiple angles potentially.
(17:49):
And how is it used? Is it a long course?
Typically, oral Propranolol is started during the proliferative
phase, usually in infancy, and continued for several months,
often until around one year of age or until growth has clearly
stopped and regression is underway.
And are there other options besides oral?
Yes. For smaller, thinner or more
superficial lesions, topical timolol is often used.
(18:10):
Timol is also a beta blocker applied directly to the skin as
drops or gel. It can be quite effective for
the right type of lesion. So Propranolol oral or timolol
topical are the main players when intervention is needed.
What kind of specific situationsreally warrant this beta blocker
treatment? Think back to the complications
we discussed. Propranolol would be indicated
(18:31):
for lesions causing or threatening vision loss like
large eyelid hemangiomas, airwayobstruction, feeding
difficulties, large facial lesions causing disfigurement or
ulcerated hemangiomas which can be painful and bleed or get
infected. Also rarely for very large
lesions causing heart stream. OK, let's run a quick scenario
then, like an MSRA question might pose.
(18:52):
Imagine you have a three month old infant presenting with a
rapidly enlarging bright red lesion right on the tip of their
nose. It's growing quickly.
Based on what we've just discussed, what's the most
likely next step in management? OK.
So three month old rapid growth tip of the nose, that's a
cosmetically sensitive area prone to disfigurement and it's
clearly in the proliferative phase.
(19:14):
Functional impairment is an immediate, but the risk of
significant long term cosmetic issues is high.
Therefore, the most likely next step according to guidelines
would be to initiate treatment to halt proliferation and induce
regression. The preferred first line
treatment would be oral procranolol.
Perfect example of linking the features, location, age, growth
(19:34):
phase to the likely management strategy.
Are there any other treatment options, maybe less common these
days? Yes, although they are used much
less frequently now that beta blockers are established as
first line intralesional corticosteroids.
Injecting steroids directly intothe lesion can sometimes be used
to slow proliferation, particularly maybe for smaller
localised lesions or if beta blockers aren't suitable.
(19:57):
Interferon Alpha has been used historically and very specific,
often severe or life threateningcases, but it has significant
side effects. And surgical excision is an
option too. They're cutting it out.
Yes, but it requires careful consideration due to the
vascularity and bleeding risk. It's usually reserved for
smaller lesions that are easily removable, or sometimes for
addressing residual tissue or scarring after involution has
(20:20):
occurred naturally or with treatment.
For very large or life threatening lesions, a
multidisciplinary approach involving paediatricians,
dermatologists, surgeons and maybe interventional
radiologists for procedures likeembolization might be needed.
So Propranolol is really the headline treatment for
problematic cases, but other tools exist in the toolbox for
specific situations. Now, looking long term, what's
(20:43):
the prognosis like for these babies generally?
Generally speaking, the prognosis is excellent, really
very good. It's good to hear.
As we've emphasised, the vast majority regress spontaneously
without causing any long term problems or complications.
That Natural History is key. And by what age are they
typically gone by? You mentioned 1012 earlier.
Yeah, Complete resolution usually occurs by age 5 to 10
(21:06):
years, sometimes stretching to 12.
The bulk of the regression oftenhappens by school age.
Does the skin always look completely normal afterwards or
can you sometimes tell somethingwas there?
Not always absolutely perfectly normal, no.
While often the cosmetic result is very good, especially for
smaller ones, some cases might be left with minor lingering
(21:27):
effects, like what you might seesome residual telangitasias,
those are tiny widened blood vessels on the surface.
Or there might be slight textural changes in the skin,
maybe a bit of wrinkling, atrophy or slight discoloration
where the Hemangioma used to be.But overall, the functional
outcome is usually excellent andthe cosmetic outcome is
typically very favourable, especially compared to how it
(21:48):
looked during the growth phase. That's definitely reassuring
news for parents. Finally, let's just quickly
recap the potential complications, reinforcing why
we monitor them closely and sometimes intervene.
Right, So important to remember most lesions do not 'cause
complications, but the potentialones we've touched on include
ulceration. Where the skin breaks down.
Exactly, that can be quite painful, prone to bleeding and
(22:12):
can get infected. Bleeding itself can happen,
though often it's minor, maybe just oozing.
Unless the lesion is traumatisedor it's part of a syndrome like
Kassebach Merit and infection ofthe lesion itself is possible,
especially if it ulcerates. OK.
And linking back to management triggers.
Exactly. The most significant
complications, the ones that usually drive treatment
(22:33):
decisions, arise from that functional impairment caused by
the lesion's location and size, obstructing vision, blocking the
airway, interfering with feeding, etcetera.
That's why regular monitoring bya healthcare professional is
crucial, especially during infancy, to catch these issues
early and intervene appropriately with treatments
like Propranolol if needed. OK, brilliant.
We've just done a really high yield deep dive into infantile
(22:57):
Hemangioma, also known as strawberry and Ivis.
We've covered its definition, that fascinating Natural History
of growth and shrinkage, potential causes, and those
important associations like PACEand CASABAC merit the red flags
like location and number. The risk factors, what's
happening at the cellular level,what else it could be, those
differentials, how common it is and who tends to get it, what it
(23:20):
looks like clinically and its growth pattern.
How we investigate it when needed.
The crucial management approach focusing on watchful weighting
but using Propranolol for problematic cases and finishing
with the generally excellent prognosis alongside those
potential complications to watchfor.
It's a lot packed in, but hopefully focusing on these core
concepts, especially the NaturalHistory and the indications for
(23:41):
treatment, is really key for mastering this topic for
revision. Absolutely.
For more free MSRA revision resources, remember to visit
freesra.com and for the full Premium Revision Toolkit, head
over to pastms-r.com. Keep up the great work with your
revision. Keep reviewing and best of luck
with your studies.
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