Strawberry Naevus

Synonym: infantile haemangioma

Strawberry naevus is the name given to a haemangioma which occurs in infancy, usually on the face.

• The lesions may be present at birth, or may develop in the first few weeks after birth.
• They may begin as a small flat red area, but usually develop into a raised dimpled (strawberry like) lesion.
• The lesions typically grow in size as the child grows, until the age of approximately 3-4 years, when they start to regress spontaneously.
• This process can take up to 10 years.¹

There are currently no recent published prospective studies examining the incidence of haemangiomas. Older studies were performed before the discrimination of "haemangiomas" from other vascular birthmarks was well-established.²

• Strawberry naevi are very common, occurring in about 3 to 5% of babies.
• They are rather less common in children of Afro-Caribbean origin and even more uncommon in those of Asian extraction.
• There is a 3:1 female preponderance.³
• In children with a birth weight of less than 1kg, there is a 1 in 4 chance that they will develop a haemangioma.⁴ In this group the sex ratio is equal.³

• One third of strawberry naevi will be evident at birth, the remainder developing in the first 4 weeks after birth.
• In the initial stages, the lesions may be bluish or red spots or patches, and the superficial lesions may remain flat. Deeper lesions have a bluish appearance. Compound lesions may occur having both superficial and deep areas.
• The vast majority of strawberry naevi occur on the head and neck, but occasionally these lesions may occur at other sites throughout the body
• The vast majority of strawberry naevi cause no symptoms at all, but visceral haemangiomas, or large superficial haemangiomas may cause problems.

• Angiosarcoma
• Arteriovenous malformation
• Congenital haemangioma (that does not involute)
• Teratoma
• Venous malformation
• Diffuse neonatal haemangiomatosis

• Usually, no investigations will be required but if an infant has 3 or more visible strawberry naevi, a whole body MRI should be performed to rule out internal lesions
• If there is uncertainty about the lesion, MRI and doppler ultrasound may be used. Doppler may be useful to assess the persistence, increase or resolution of A-V fistulae as this can influence the decision to observe or to treat.⁵
• Biopsy, if required, should be undertaken with caution as these lesions are very vascular.

• Periorbital haemangiomas, particularly with involvement of the upper eyelid, require refraction with retinoscopy to check for visual disturbances, especially astigmatism and to prevent visual deprivation amblyopia.
• Rapidly growing haemangiomas can impinge on vital structures of the head and neck, particularly the airway or auditory canals. Large haemangiomas of the beard area have a higher incidence of upper airway haemangiomas. This may present as noisy breathing or stridor.
• An infantile haemangioma over the midline of the back may be a sign of an underlying occult spinal dysraphism, such as a tethered cord. MRI is indicated or ultrasound if the infant is younger than 5 months.

• The majority of these lesions will involute spontaneously over time and will require no treatment. This is especially true of those in premature babies.⁴
• Occasionally plastic surgery will be required following involution of the lesion to remove redundant folds of floppy skin
• Pulsed dye laser may be valuable if they are not resolving well, or are in places that cause particular embarrassment:
  • It is used to treat ulcerating haemangiomas.
  • Laser treatment gives a better outcome than observation.³ Sometimes treatment causes pain.
  • Not all children need active treatment.⁶
• A number of drugs have been used to treat proliferation of these tumours:
  • Intralesional corticosteroids slow proliferation.
  • Those who fail to respond to steroids may respond to interferon-α2a, but it can have toxic effects in some and spastic diplegia has been described.^7,8
  • Imiquimod, an immune response modifier, has also been used. Such treatment is generally reserved for dangerous and proliferating lesions.⁹ It has been shown to be more efficacious in superficial lesions.¹⁰
• Surgical excision of proliferating haemangiomas needs care as they are very vascular.

Larger, visceral or life threatening lesions may be treated with a combination of surgery and embolisation therapy.

• Large facial haemangiomas may cause problems with sight, hearing, breathing, swallowing and speaking. They should be treated immediately to prevent further problems.
• Bleeding or ulceration may occur.
• Visceral haemangiomas may produce symptoms due to bleeding or mass effect. The symptoms will vary according to site.
• Occasionally, they may impinge on vital structures, ulcerate, bleed, induce consumptive coagulopathy, or cause high output cardiac failure or significant structural abnormalities. Those on the face are of greatest concern.

They are the commonest tumours in infancy and usually resolve without problem.