They are classified as either haemangiomas or vascular malformations.
Historically, vascular anomalies have been poorly treated due to the confusion that once surrounded these conditions. Misdiagnosis and mistreatment were common, and still persist today.
Recently, however, improved medical knowledge and understanding, and improved multi-disciplinary care, have led to better patient outcomes. There are several treatment options available to patients, but treatment needs to be adapted to individual cases, with timing and judgement being critical in determining the success of the chosen intervention (surgical or otherwise).
A haemangioma is a benign overgrowth of blood vessels on the skin that appears as a soft, raised swelling. Also referred to as strawberry naevi, strawberry haemangiomas, capillary haemangiomas and cavernous haemangiomas, these blemishes can be found anywhere on the body, although 70% occur in the head and neck region. They are typically crimson red in colour with a slightly dimpled surface, hence the name strawberry.
Although often referred to as birthmarks, haemangiomas usually appear just after birth. They rapidly expand over a period of months, reaching a plateau at around one year, after which they start to shrink and fade. Most have totally vanished by the time a child is ten, and the majority come and go without causing any problems.
Occasionally, however, haemangiomas can cause complications such as bleeding, ulceration and infection, and these will require treatment.
What treatment is available for haemangiomas?
Haemangiomas that ulcerate and bleed can be managed with dressings and antibiotic steroid treatments. Although haemangiomas on the face can cause distressing aesthetic deformity, these are usually treated conservatively during the growth phase. Treatment will be more rigorously pursued in the case of:
• Haemangiomas which obscure vision which, if untreated, can cause amblyopia, or lazy eye;
• Haemangiomas affecting the airways; and
• Multiple haemangiomas that put pressure on the heart due to increased cardiac output
Steroids, either injected directly into an isolated haemangioma or given to a patient orally, are the first line of treatment.
In the case of larger haemangiomas, or those that have ulcerated, permanent fatty remnants and baggy excess skin may be left behind. Patients with these conditions will require surgery to normalise the affected area. Very occasionally, haemangiomas can also lead to facial asymmetry, requiring specialised plastic surgery and maxillofacial treatment in later childhood.
Plastic surgeons also interact with radiologists in certain case of haemangioma, often using a successful combination of surgery and interventional radiology to treat the affected areas.
Vascular malformations, unlike haemangiomas, are present at birth and do not have independent phases of growth or recession. Instead, they grow in proportion to a baby and are classified according to the dominant blood vessel type they contain.
The main vascular malformations are:
Capillary malformations – also known as port wine stains (PWS) and nevus flammeus
These birthmarks persist throughout life, and are equally common in boys and girls and most commonly involve the face. The affected skin has a red wine colour due to the presence of dilated capillaries (the smallest blood vessels) in the dermis, or the deep layer, of the skin. The malformation will grow in proportion to the child and may become darker in colour and develop a more uneven surface in adulthood.
Apart from the perceived disfigurement, capillary malformations rarely have any symptoms or complications. They can be dealt with very effectively with laser treatment.
These malformations involve the lymph system, and include conditions known as lymphangioma circumscriptum, cavernous lymphangiomas and cystic hygromas. Most lymphatic malformations are present at birth or will develop before the age of two, and will not shrink or fade on their own. They are equally common in boys and girls. Their appearance is variable, from small blister-like marks on the skin, to large swellings in the neck, limbs or face. In some cases there can be bleeding or infection causing sudden enlargement.
Lymphatic malformations can cause significant airway problems. If necessary, treatment may involve injection into the swelling, or surgery, which can be complicated
Arteriovenous malformations (AVM)
AVMs are rare and potentially dangerous lesions that occur mainly in the scalp, head and neck region. They can lead to dramatic complications and can pose a fatal threat to patients. Enlargement of an AVM may be triggered by trauma or puberty, and there will often be visible swelling in the skin over the affected area, which is often blue in colour. If an AVM is seen to be growing and bleeding, then treatment is urgently required. In some cases, so much of the patient’s blood will be going to an AVM that the heart is unable to keep up – this can cause cardiac failure and also requires urgent treatment.
There are several treatment options available, such as injections of various materials into the affected area. This form of treatment is called embolisation, and is designed to stop the blood-flow to the lesions. Surgery is also possible, although the blood vessels involved often need to be accurately investigated before any surgery is undertaken. The surgeon can then decide exactly what can be done and should explain the options to you at this point, although surgical excision is the mainstay of operations performed on AVM patients.
Is this treatment available on the NHS?
Treatment options for all vascular anomalies are available on the NHS.
Who will I see as patient?
The management of major vascular anomalies should be multi-disciplinary, as these conditions can affect any part of the body and treatment can involve several medical disciplines. A multi-disciplinary team will be made up of specialists working together to make sure that the best possible treatment is given. These specialists may include the following:
• Plastic Surgeon
• Vascular Surgeon
• Interventional Radiologist
The British Association of Skin Camouflage