Recorded on September 16, 2026
Vascular Birthmarks in Infants: When to Observe and When to Refer
Key takeaways from CHKD’s September 2026 Provider Relations CME Lunch & Learn
Vascular birthmarks are common in infancy, but distinguishing a low-risk lesion appropriate for observation from one requiring prompt specialty evaluation can be challenging. For infantile hemangiomas in particular, early risk stratification is important because rapid proliferation occurs during the first months of life.
During a recent CHKD Provider Relations CME Lunch & Learn, specialists from CHKD’s multidisciplinary Vascular Anomalies Clinic discussed practical considerations for evaluating infantile hemangiomas, vascular malformations, and other vascular lesions in the primary care setting.
Infantile Hemangiomas: Recognize High-Risk Lesions Early
Infantile hemangiomas typically become apparent during the first few weeks of life and proliferate most rapidly during the first three to five months. Many reach approximately 80% of their ultimate size by 3 months of age.
This early growth period creates a relatively narrow window for identifying lesions at risk for functional impairment, ulceration, disfigurement, or other complications.
Prompt specialty evaluation should be considered for hemangiomas involving:
Periocular structures
Nose, lips, or oral cavity
Airway
Large facial segments
Lumbosacral midline
Female breast tissue
Multiple hemangiomas
Rapid growth, ulceration, functional compromise, or diagnostic uncertainty should also lower the threshold for referral.
Which Lesions Can Be Observed?
Small, uncomplicated hemangiomas in low-risk locations may be appropriate for observation. Selected small, thin, superficial lesions may also be candidates for topical timolol when the diagnosis is clear and treatment is clinically appropriate.
Observation becomes less appropriate when the lesion is in a high-risk location, follows an atypical growth pattern, threatens function, or does not respond as expected.
For problematic infantile hemangiomas, oral propranolol is first-line therapy and has substantially changed management, reducing the need for surgical intervention in many patients.
When It May Not Be a Hemangioma
An important component of risk assessment is recognizing lesions that do not have the typical clinical course of an infantile hemangioma.
Vascular malformations, including capillary, venous, lymphatic, arteriovenous, and combined malformations, have different natural histories and management considerations. Unlike infantile hemangiomas, vascular malformations are biologically present at birth and generally grow proportionally with the child.
Features warranting further evaluation include:
Significant pain
Abnormal firmness
Progressive or unexplained swelling
Bleeding abnormalities
Atypical onset or appearance
Growth inconsistent with the expected course of an infantile hemangioma
Findings concerning for an associated syndrome
Certain locations can also provide important diagnostic clues. Facial capillary malformations in high-risk distributions may warrant evaluation for Sturge-Weber syndrome, while lumbar vascular lesions may be associated with underlying spinal abnormalities.
When to Refer
For referring clinicians, the threshold for specialty evaluation should be low when a vascular lesion:
Involves a high-risk anatomic location
Is rapidly enlarging
Threatens vision, breathing, feeding, or other function
Is painful, firm, ulcerated, or otherwise atypical
Presents with multiple hemangiomas
Raises concern for an associated syndrome
Cannot be confidently classified
Does not follow the anticipated clinical course
Early referral does not necessarily mean that treatment is required. Rather, it provides an opportunity to establish the diagnosis, assess risk, and determine whether observation or intervention is appropriate while the therapeutic window is still optimal.
Multidisciplinary Vascular Anomalies Care at CHKD
CHKD’s Vascular Anomalies Clinic provides multidisciplinary evaluation and management of vascular tumors and malformations, bringing together expertise from dermatology, otolaryngology, hematology-oncology, plastic surgery, genetics, radiology, and interventional radiology.
For high-risk, complex, or diagnostically uncertain lesions, the team can assist referring providers with diagnosis, risk stratification, and management planning.
Learn more about CHKD’s Vascular Anomalies Clinic and refer a patient
References:
Darrow DH, Greene AK, Mancini AJ, Nopper AJ. AAP Clinical Report: Diagnosis and management of infantile hemangioma; Executive Summary. Pediatrics 2015; 136:786-91.
Krowchuk DP, Frieden IJ, Mancini AJ, Darrow DH, et al. Clinical practice guideline for the management of infantile hemangiomas. Pediatrics. 2019;143. pii: e20183475. doi: 10.1542/peds.2018-3475.
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