The Dermatology Practice.

Vascular Birthmarks

Strawberry nevus, usually appears after birth. It is most commonly noticed at a few days of life. It may be superficial, mixed or deep. There are usually 3 phases of growth. The first being a rapid growth or proliferative phase at around 5 to 8 weeks. The next phase is a resting or plateau phase occurring at around the first year of life. Last of which, is the involution phase

There are 2 other hemangiomas, namely the rapidly involuting congenital hemangioma (RICH) and non- involuting congenital hemangioma (NICH) which do not follow this classical growth phases. The former is fully formed at birth, then involutes spontaneously and resolves by the child’s first or second birthday. The latter is fully formed at birth but does not involute and shrink.

When do we worry?

Most of these infantile hemangiomas do not need treatment and we can look forward to spontaneous involution. However, do seek EARLY treatment if the following are present:

  1. Ulceration, bleeding or pain
  2. Locations that may affect function such as being near or at the eyes, lips, nose, ears, jawline, diaper area, scalp especially if > 2 cm
  3. Segmental involvement of the face (may need to evaluate for PHACES syndrome -posterior fossa malformations, hemangiomas, arterial abnormalities, cardiac abnormalities, eye abnormalities, sternal cleft defect) or over the lower back or perineum (LUMBAR syndrome – Lower body hemangioma, urogenital anomalies, myelopathy, bony deformities, anorectal anomalies, renal anomalies or PELVIS syndrome – Perineal hemangioma, external genital malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus, skin tag)
  4. Multiple > 5 (will need screening liver ultrasound, if multiple liver IH, will need to check for hypothyroidism)
  5. Concern about cosmesis
How do we treat?

Local treatments

  • Topical timolol for small (<2cm) and superficial lesions
  • Topical steroid (used less these days)
  • Steroid injection (used less these days)

Oral treatments

  • Propranolol
    • Useful in superficial lesions that are large, and especially if there are the above complications
    • Most often used in mixed (both superficial and deep) and deeper lesions
  • Steroids

Laser therapy

  • Pulsed dye laser
    • Can help as an adjunct to the above treatments in selected cases which are ulcerated or bleeding
    • Helps to reduce redness and improve textural changes that may be left behind after the hemangioma involutes

Capillary Malformation


Port-Wine Stain

A port wine stain, a type of capillary malformation, is a red mark or patch that is usually present at birth. This can darken, thicken and enlarge as the child grows older. There is usually no family history although recently, a small genetic change occurring in the birthmark in a gene called GNAQ has been discovered.

When do we worry?


  • Large segmental involvement of face involving especially the forehead, scalp and eyelid may be associated with Sturge weber syndrome (a condition with neurological abnormalities and glaucoma)
  • Extensive involvement of the limbs may be associated with increase growth of the limb, also known as Klippel-Trenaunay syndrome
How are they treated?

Pulsed dye laser is the treatment of choice. Treatments given early in life, preferably below the age of one year, provide better outcome as there is a risk the lesions thicken with time and become more stubborn to treatment. The treatments are given around 6 to 8 weeks apart and around 8 to 10 sessions may be required. Not all lesions will improve but the aim is to lighten them significantly before school going age.

Nevus Simplex

Nevus Simplex

A nevus simplex, another type of capillary malformation, is commonly known by a few names such as salmon patch, stork bite (nape of neck) and angel kiss (forehead, eyelids) depending on their location. These are also present at birth and fade with time.

How are they treated?

Most of the time there are no underlying associated conditions and these lighten with time. One may choose to treat with pulsed dye laser if it doesn’t fade and affects cosmesis. Although, the eyelid, forehead patches tend to fade by the second year of life.