Laser and Skin

Haemangioma and cherry angioma: one name, two things

The word haemangioma covers two findings that have almost nothing in common. The infantile haemangioma, the strawberry mark, appears in up to 5% of newborns, grows fastest between 1 and 3 months of age and in most children shrinks away on its own by the age of 7, so the question is whether to treat at all and, if so, how early. The cherry angioma of adults, also sold under the name senile haemangioma, starts at about 30 to 40, is present in 75% of people over 75, never goes away by itself and is removed on request with a vascular laser, usually in 1 to 2 sessions.

Two findings that share a word

Ask a paediatrician about a haemangioma and you will hear about a raised red lump that appears in the first weeks of life, grows for a few months and fades over years. Ask a dermatologist and you may hear about the ruby-red dots that collect on the trunk of anyone over 40. The first is the infantile haemangioma, the strawberry mark, a benign tumour of blood vessel cells. The second is the cherry angioma, also called senile haemangioma or Campbell de Morgan spot, a tiny cluster of dilated capillaries. They share a word, a colour and the fact that both are harmless in themselves, and that is where the overlap ends.

The numbers already separate them. Infantile haemangiomas occur in as many as 5% of infants and are more common in girls, in babies born before 37 weeks, in low birthweight babies and in twins. Cherry angiomas are found in about 7% of adolescents, in 5 to 41% of people in their twenties depending on the study, and in 75% of adults over 75. One is a diagnosis of the first months of life with a narrow window for decisions; the other is a cosmetic question that can wait for years. The overview of red marks places both among their relatives.

The infant haemangioma runs on its own clock

About 1 in 3 infantile haemangiomas is visible at birth, usually as a pale or faintly red patch; the rest appear in the first days to weeks. The most rapid growth takes place between 1 and 3 months of age, and in most cases growth is complete by 5 months, although deep and large lesions can keep enlarging until 6 to 12 months. After a plateau, shrinking starts at around 12 months and takes years: roughly half of all haemangiomas have gone by the age of 5, almost all by 7, and large ones may continue to shrink until 8 to 10.

This course is why watchful waiting is accepted for a small haemangioma in an uncritical spot. Waiting is not ignoring: the lesion is photographed from the front and the side at every visit, and visits are frequent while growth is running, typically every 2 to 4 weeks in the first months. Shrinking is not always vanishing either. In published series 50 to 65% of untreated haemangiomas leave a trace, such as loose skin, fine visible vessels or a paler patch, and the thicker the lesion, the likelier the residue. That residue is what lasers and surgery are mostly used for later, from about school age.

When the infant case is treated early

A minority of infant haemangiomas cannot wait, and location, size and behaviour decide, not appearance. A lesion near the eye can block the visual axis within weeks; one on the nose, lip or ear grows into structures that heal poorly; one on the jaw, chin or neck may be accompanied by a second haemangioma in the airway; one in the nappy area or a skin fold tends to break open. Ulceration is the most common complication, affects about 15% of haemangiomas, peaks around 4 months of age and leaves a scar. A large facial haemangioma or 5 or more separate lesions prompt a look at underlying organs such as the liver.

Because the growth window closes early, the 2019 guideline of the American Academy of Pediatrics asks that a potentially problematic haemangioma is seen by 1 month of age. The standard treatment is oral propranolol at 2 to 3 mg per kilogram per day, continued for at least 6 months and often until 12 months of age, occasionally up to 18 months. Small, thin, superficial lesions can be treated with timolol 0.5% gel 3 times a day, started before 3 months for lesions under 5 square centimetres. The pulsed dye laser at 595 nm has a narrower role in infancy: it helps ulcerated lesions heal and clears leftover redness, and the NHS notes that it works best when started between 6 months and 1 year of age; it does not shrink a deep haemangioma. None of this is a decision for a cosmetic salon. It belongs in a paediatric or dermatology clinic, and quickly.

The adult cherry angioma stays, and treatment is optional

A cherry angioma is a dome-shaped, bright red papule of 1 to 5 mm, often with a pale halo, on the trunk, upper arms and thighs and rarely on the face, hands or feet. It starts at about 1 mm, reaches around 2 mm by the age of 50 and never regresses. The cause is unknown, mutations in the GNAQ and GNA11 genes are frequent, and sun plays no part, which is why the covered back carries as many as the forearms. A sudden crop of dozens within a few weeks is unusual and has been linked to pregnancy, some medicines and rarely to internal disease, so that pattern gets a medical look; the slow accumulation over decades does not.

Treatment is for people who are bothered by the spots; nobody needs it. The tools are a vascular laser (KTP at 532 nm, pulsed dye at 595 nm or Nd:YAG at 1064 nm), an electrocautery needle, shave removal or cryotherapy. In a comparative study of 2003 the KTP laser cleared lesions with 1 treatment on average against 2 for electrocautery, with a maximum of 3 sessions at 2-month intervals. A 2011 comparison found that the 1064 nm laser needed fewer sessions than the 532 nm laser but caused more pain, swelling and scarring, while the 532 nm laser left more temporary darkening. A systematic review of 10 studies in 2020 concluded that no single method is superior, that the pulsed dye laser scores best for comfort and that the 1064 nm laser produces the fewest pigment problems in darker skin. If your skin is Fitzpatrick type IV to VI, that last point chooses the device; the Skin Type Finder tells you where you sit.

A dermatologist treats 10, 20 or 30 spots in one appointment of 15 to 30 minutes. Each spot turns grey or dark, forms a small crust that falls off within 5 to 10 days and leaves a faint mark that fades over 4 to 8 weeks. Blood thinners such as aspirin or warfarin raise the chance of bruising and a longer crust, so mention them beforehand. Electrocautery is usually swapped for a laser in anyone with a pacemaker, and the treated area should stay out of strong sun until the crust is gone to avoid a pale or dark mark. Prices are quoted per session, commonly 100 to 300 EUR in Western Europe and 150 to 400 USD in the US for a cluster on the trunk. New angiomas keep forming because the tendency stays, so people who want a clear trunk plan a short session every 2 to 3 years rather than chasing every new dot.

What both cases have in common

The assessment comes before the device, at any age. A cherry angioma has 4 look-alikes that matter: pyogenic granuloma, angiokeratoma, nodular basal cell carcinoma and amelanotic melanoma, a pigment-free melanoma that presents as a red bump and bleeds more readily than an angioma. A red spot that bleeds without injury, grows visibly within a few weeks or changes its surface is examined with a dermatoscope and, in doubt, cut out and sent to the laboratory rather than lasered away, because a laser destroys the tissue a pathologist would need.

For the same reason, freezing sprays from the pharmacy are the wrong tool. They are made for warts, cool only the surface, and on a vascular lesion they neither close the vessel nor spare the skin around it, so the typical result is a blister, a scar and an angioma that is still there. Several countries have drawn a legal line as well: Germany has reserved laser treatment of vascular and pigmented skin changes for doctors since the end of 2020, and in most of Europe and North America the infant case sits in hospital paediatrics or dermatology while the adult case is a dermatologist's 20-minute job. Whoever holds the laser, the order is the same: name the lesion, then decide whether it needs to go at all.

When a red mark needs a look within days

Frequently asked

Does a baby's haemangioma need treatment?

Most do not. Small haemangiomas in uncritical spots are photographed and watched, because roughly half have gone by the age of 5 and almost all by 7. Near the eye, on the nose, lip or ear, in the nappy area, or when ulcerated or growing fast, treatment starts early, ideally after assessment by 1 month of age.

What is the difference between a haemangioma and a cherry angioma?

The infantile haemangioma is a benign vessel tumour of the first months of life that grows and then shrinks by itself. The cherry angioma is a 1 to 5 mm red dot that appears in adults from about 30 to 40, stays for life and only matters cosmetically.

Do cherry angiomas go away on their own?

No. They persist and increase in number with age, and 75% of people over 75 have them. Removal is a cosmetic decision, not a medical one.

How many laser sessions does a cherry angioma need?

Usually 1 to 2. In a comparative study the KTP laser cleared lesions with a single treatment on average, and 10 to 30 spots can be treated in one 15 to 30 minute appointment; a small crust falls off within 5 to 10 days.

Can I use a wart freezing spray on a red spot?

No. Those sprays are made for warts, cool only the surface and neither close the vessel nor spare the surrounding skin, so they tend to leave a blister and a scar with the angioma still in place.

When should a red spot be examined quickly?

When it bleeds without injury, grows visibly within a few weeks or changes its surface, at any age. In a baby, also when it sits near the eye, nose, lip, ear or nappy area, breaks open, or when there are 5 or more of them.

Sources

• Krowchuk DP et al., Clinical Practice Guideline for the Management of Infantile Hemangiomas, Pediatrics 2019;143(1):e20183475 · up to 5% of infants; fastest growth between 1 and 3 months, complete by 5 months; referral by 1 month of age; propranolol 2 to 3 mg/kg per day for at least 6 and often 12 months; timolol, laser and surgery roles. Publisher page answers 403 to automated requests, abstract verified via the PubMed record 30584062
• NHS: Birthmarks · strawberry marks grow for 6 to 12 months and shrink and disappear by age 7; more common in girls, babies born before 37 weeks, low birthweight and multiples; laser works best started between 6 months and 1 year; when to see a GP
• StatPearls: Cherry Hemangioma (NCBI Bookshelf) · 7% of adolescents, 5 to 41% of people in their twenties, 75% of adults over 75; 1 to 5 mm; trunk and proximal limbs; GNAQ and GNA11 mutations; electrocautery, shave, cryotherapy, pulsed dye, KTP and other lasers; amelanotic melanoma as differential
• Buslach N et al., Treatment Modalities for Cherry Angiomas: A Systematic Review, Dermatol Surg 2020;46(12) · 10 studies; pulsed dye, KTP, Nd:YAG 1064 nm, intense pulsed light, cryotherapy, electrosurgery and sclerotherapy all effective, no method superior; pulsed dye preferred for less pain, Nd:YAG fewer pigment complications in darker skin. Publisher page answers 403 to automated requests, abstract verified via the PubMed record 33252464

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This guide is for general information. It does not replace medical or professional cosmetic advice or an examination.