Cochrane Review: Interventions for infantile haemangiomas (strawberry birthmarks) of the skin
Authors: Leonardi‐Bee Jo , Batta Kapila , O'Brien Carol , Bath‐Hextall Fiona J 
Published: March 2012

Background

Infantile haemangiomas (also known as strawberry birthmarks) are soft, raised swellings of the skin which are usually uncomplicated and tend to regress spontaneously over time. Some haemangiomas occur in high‐risk areas or can develop complications; therefore, intervention may be necessary. Various interventions have been proposed, but it is unclear whether any of these interventions are effective.

Objectives

To assess the effects of interventions for infantile haemangiomas.

Search methods

We searched the following databases up to March 2011: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, AMED (Allied and Complementary Medicine), LILACS (Latin American and Caribbean Health Science Information database), CINAHL, and reference lists of articles. We also searched online trials registries for ongoing trials and grey literature.

Selection criteria

We included children with haemangiomas.

Data collection and analysis

Two authors independently screened titles, abstracts, and the full text of publications; extracted data; and assessed risk of bias.

Main results

We included 4 studies with a total of 271 participants.

One randomised controlled trial (RCT) compared pulsed dye laser (PDL) therapy versus the 'wait and see' approach. At one year PDL was significantly more likely to result in complete clearance. The risk ratio (RR) was 6.10 (95% CI [confidence interval] 1.89 to 19.64); however, there was no difference when clearance was defined as 'complete or minimal residual signs'. Redness was significantly less pronounced in the PDL group, but no differences were seen for height or surface area. Significant increases in atrophy and skin hypopigmentation were seen in the PDL group.

One very old RCT assessed radiation versus mock‐radiation; there was no significant difference in clearance at six years (RR 1.08, 95% CI 0.63 to 1.87) between the groups, irrespective of the size of the haemangioma and the skin colour.

In one small RCT there was a significantly greater reduction in size of the haemangioma with oral prednisolone compared to intravenous methylprednisolone at three months (mean difference [MD] was 58 mm [95% CI 29.24 to 86.76]), and one year. Similar adverse events occurred in both groups.

In another small RCT there was a significant reduction in the surface area of the haemangioma with bleomycin compared to the control (RR 21, 95% CI 1.34 to 328.86).

Authors' conclusions

This review has found limited evidence from individual RCTs to support some of the existing interventions (corticosteroid and PDL) for infantile haemangiomas. There is a need for further high‐quality RCTs to validate the findings from these studies, and RCTs to assess the effect of other treatments, in particular relating to propranolol.

Plain Language Summary

Treatments for strawberry birthmarks of the skin in infants and children

Infantile haemangiomas are soft, raised swellings on the skin, often with a bright, red surface. They are a non‐cancerous overgrowth of blood vessels in the skin. They are commonly known as 'strawberry birthmarks', 'strawberry naevi', or 'capillary haemangiomas'. They occur in five per cent of babies, with the majority appearing within the first few weeks of life, and reach their full size at about three to six months of age. The vast majority are uncomplicated and will shrink on their own by five to seven years of age and require no further treatment. However, some infantile haemangiomas may occur in high‐risk areas (such as near the eyes and nose which can result in impairment to vision and airway obstruction, respectively) and some of them are disfiguring and psychologically distressing to the children and their parents. Some may also develop complications so early medical treatment may be necessary. Corticosteroids are currently the standard treatment; however, it is not known which of a variety of treatments is best.

Four trials (ranging from 20 to 121 participants) were included in this review. Two assessed treatments which are no longer used (bleomycin and radiation), with neither trial finding clinically important improvements. From the other two trials limited evidence in relation to clinically important improvements were seen.

One trial assessed the use of photodynamic laser (PDL) therapy. Haemangiomas were more likely to completely clear with PDL when compared to a 'wait and see' approach at one year. However, there were significant side‐effects, and it was noted that most of the birthmarks treated with PDL would have resolved naturally over time.

One trial compared an oral corticosteroid (prednisolone) with an intravenous corticosteroid. Haemangiomas were more likely to reduce in size using the oral corticosteroid as compared to the intravenous corticosteroid at three months and one year. Similar numbers of side‐effects were being seen in both groups.

We found eight ongoing trials, four of which were designed to assess the effectiveness of oral propranolol either against placebo or an oral corticosteroid. Propranolol has become the second‐line treatment since the publication of the protocol of this review in 2007; therefore, it is important that this review is updated within the next three years so these studies can be assessed and added to the evidence base to inform clinical practice.

There is limited evidence of the effectiveness of treatments for those birthmarks that require treatment because the data has come from small trials. The treatments used for haemangiomas need to be tested in large, well‐designed trials.