Port-wine stain or infantile hemangioma: how to tell them apart

How to tell them apart

At birth, a port-wine stain is usually already visible, while a hemangioma may be absent or only a faint mark. In growth, a port-wine stain grows in proportion with the child, while a hemangioma grows rapidly during the first months.

In colour, a port-wine stain is pink, red or purple, while a hemangioma is bright red or bluish. In surface, a port-wine stain is usually flat and a hemangioma may be raised. Over time a port-wine stain persists and can darken and thicken, while a hemangioma gradually involutes.

In treatment, port-wine stains are treated with vascular laser, especially pulsed dye laser, while hemangiomas are observed or treated with oral propranolol when needed. In associations, port-wine stains in certain facial locations can be linked with Sturge-Weber syndrome, and large segmental facial hemangiomas can be linked with PHACE syndrome ^[1][5][6].

Port-wine stain

A port-wine stain, also called a capillary malformation, is a congenital change in the small blood vessels of the skin. It is typically present at birth, flat, pink to red or purple, well demarcated, and persistent ^[3].

As the child grows, the mark grows in proportion with the body. Over years it can become darker and thicker, and the surface may become rougher or cobblestoned.

When a port-wine stain needs further assessment

Particular attention is given to a port-wine stain on the forehead, upper eyelid or the ophthalmic (V1) distribution of the trigeminal nerve. These distributions can be associated with Sturge-Weber syndrome ^[5].

• Neurological problems or seizures
• Glaucoma and other eye complications
• Vascular changes in the membranes covering the brain
• A need for eye and neurological assessment depending on the site and size of the stain

Infantile hemangioma

An infantile hemangioma is a benign vascular tumour of childhood. It may not be obvious at birth, then appears and grows during the first weeks of life. It follows a pattern of appearance, rapid growth, plateau, then gradual involution ^[1][4].

Superficial hemangiomas are bright red, raised and soft or compressible. Deep hemangiomas appear bluish or skin coloured as a swelling under the skin and are less obvious. Both types can occur together in the same child.

When a hemangioma needs treatment

Most infantile hemangiomas need only observation. Early assessment matters for the higher risk group, and where treatment is needed, oral propranolol is the first line option in many suitable cases ^[1].

• Growing very rapidly
• Close to the eye with a risk to vision
• Around the nose or mouth
• Causing difficulty with feeding or breathing
• Ulcerated, painful or bleeding
• Very large or widespread
• Segmental or extensive on the face

What is PHACE syndrome

Large segmental facial hemangiomas can be associated with PHACE syndrome in some children ^[6].

• P posterior fossa brain malformations
• H hemangioma
• A arterial anomalies
• C cardiac defects
• E eye abnormalities

Do these marks disappear

Most infantile hemangiomas do involute after the growth phase, but involution takes several years and can leave fine telangiectasia, loose or redundant skin, fibrofatty tissue, or changes in skin colour and texture.

A port-wine stain usually does not fade. Untreated it persists for life and can darken and thicken with time. Pulsed dye laser is the most established treatment, lightening the mark over several sessions ^[3].

Not every red mark is a hemangioma

Many vascular skin marks look alike. Diagnosis rests on the timing of appearance, the shape, the texture, the site and the pattern of growth. These points let a dermatologist separate a port-wine stain from a hemangioma and from other vascular malformations ^[2].

When to see a dermatologist

Bring the child for assessment if there is a red mark present since birth, especially on the face, a red lesion that started enlarging quickly in the first weeks, a mark near the eye or on the eyelid, a large or multiple lesions, ulceration, bleeding or pain, or any problem with vision, breathing or feeding.

Early assessment matters because some vascular birthmarks need treatment during a narrow window to prevent complications.

Frequently asked questions

References and sources

1. [1] Krowchuk DP, et al. American Academy of Pediatrics clinical practice guideline for the management of infantile hemangiomas. Pediatrics. 2019;143(1):e20183475.
2. [2] International Society for the Study of Vascular Anomalies. ISSVA classification of vascular anomalies.
3. [3] DermNet. Port-wine stain (capillary malformation).
4. [4] DermNet. Infantile haemangioma.
5. [5] DermNet. Sturge-Weber syndrome and capillary malformations.
6. [6] DermNet. PHACE syndrome.