High-Risk IHs

IH Clinical FindingsIH Risk
 “Beard-area” IHObstructive airway hemangiomas
 ≥5 cutaneous IHsLiver hemangiomas, cardiac failure, hypothyroidism
Functional impairment
 Periocular IH (>1 cm)Astigmatism, anisometropia, proptosis, amblyopia
 IH involving lip or oral cavityFeeding impairment
 Segmental IH: IH of any size involving any of the following sites: lips, columella, superior helix of ear, gluteal cleft and/or perineum, perianal skin, and other intertriginous areas (eg, neck, axillae, inguinal region)Increased risk of ulceration
Associated structural anomalies
 Segmental IH of face or scalpPHACE syndrome
 Segmental IH of lumbosacral and/or perineal areaLUMBAR syndrome
 Segmental IH, especially of face and scalpHigh risk of scarring and/or permanent disfigurement
 Facial IH (measurements refer to size during infancy): nasal tip or lip (any size) or any facial location ≥2 cm (>1 cm if ≤3 mo of age)Risk of disfigurement via distortion of anatomic landmarks and/or scarring and/or permanent skin changes
 Scalp IH >2 cmPermanent alopecia (especially if the hemangioma becomes thick or bulky); profuse bleeding if ulceration develops (typically more bleeding than at other anatomic sites)
 Neck, trunk, or extremity IH >2 cm, especially in growth phase or if abrupt transition from normal to affected skin (ie, ledge effect); thick superficial IH (eg, ≥2 mm thickness)Greater risk of leaving permanent scarring and/or permanent skin changes depending on anatomic location
 Breast IH (female infants)Permanent changes in breast development (eg, breast asymmetry) or nipple contour
  • Categorization of IH as high risk is based on published literature (including the AHRQ review and hemangioma severity scores) and consensus of CPG subcommittee members. Given the wide variation in IH location, size, and age at presentation, the subcommittee acknowledges that there may be situations in which an IH meets high-risk criteria and, therefore, merits consultation or referral, but the practitioner and parents do not believe this is necessary or practical. Clinical judgment is always involved in such decisions, and any plan of action needs to be individualized on the basis of a number of factors, including location of the lesion, age of child, family preferences, and geographic access to care.