Version July 2025
INTRODUCTION —
Infantile hemangiomas (IH) are benign tumors of vascular endothelium and the most common tumors of childhood [1]. Despite their benign and self-limited nature, some hemangiomas can cause complications, such as ulceration or life-altering disfigurement. Occasionally, hemangiomas may compromise vital organ function or may occur in association with developmental anomalies.
The evaluation and diagnosis of IH will be discussed here. The epidemiology, pathogenesis, clinical features, complications, and management of IH are discussed separately. PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome is also discussed separately.
●(See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications".)
●(See "Infantile hemangiomas: Management".)
●(See "PHACE syndrome".)
DIAGNOSIS —
In the vast majority of cases, the diagnosis of IH can be established clinically based on the history and physical examination [2]. However, deeper subcutaneous lesions without the characteristic overlying skin changes and hepatic lesions (especially in the absence of a cutaneous hemangioma) may be very difficult to distinguish from vascular malformations or other tumors. Although imaging studies can be helpful [3-6], tissue biopsy may be needed for definitive diagnosis in cases that are atypical in appearance or behavior.
History — For a child with a vascular lesion, important aspects of the history include [7]:
●Age at which the lesion was first noted.
●Subsequent behavior of the lesion.
●Whether any imaging studies, biopsies, or prior evaluation (including subspecialty) have been performed.
●Previous treatment and response.
●History of progressive respiratory difficulty in the first several months of life, particularly if a hemangioma is in a cervicofacial or mandibular ("beard") distribution (picture 1) (may indicate the simultaneous presence of airway hemangioma). (See 'Hemangiomas with beard distribution' below.)
●History of high-output cardiac failure during early infancy in the presence of multiple (five or more) cutaneous hemangiomas (may rarely indicate the presence of symptomatic hepatic hemangiomas). (See 'Multiple cutaneous hemangiomas' below and 'Hepatic hemangiomas' below.)
●Rapid growth, along with tenseness, purpuric appearance, or widespread telangiectasias, in the presence of a very low platelet count (may indicate the Kasabach-Merritt phenomenon in the case of a kaposiform hemangioendothelioma or tufted angioma [vascular tumors distinct from IH]). (See "Tufted angioma, kaposiform hemangioendothelioma (KHE), and Kasabach-Merritt phenomenon (KMP)".)
●Any parental preconceptions: What have they already learned about the potential diagnosis and treatment options? What concerns them the most about their child's lesion(s)?
Examination — The physical examination should include [7]:
●Careful examination of the skin and mucous membranes.
●Documentation of lesion morphology, location, and approximate size.
●Documentation of the presence and severity of ulceration, bleeding, or whether there is clinical evidence of secondary infection (eg, presence of a purulent exudate). (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications", section on 'Complications'.)
●In infants with multiple (five or more) cutaneous hemangiomas, palpation of the abdomen for hepatomegaly and evaluation for abdominal bruit if clinically indicated, including evaluation for signs of high-output heart failure (eg, tachycardia, wide pulse pressure, bounding pulses, midsystolic murmur, and/or a third heart sound caused by the increased rate of ventricular filling). (See "The pediatric physical examination: Chest and abdomen".)
●In children with segmental hemangiomas of the upper half of the body, the chest and abdomen examination may reveal suprasternal skin defects or supraumbilical raphe associated with PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome. (See "PHACE syndrome", section on 'Ventral midline anomalies'.)
●In children with segmental hemangiomas over the lower half of the body, the presence of anorectal, urogenital, or cutaneous anomalies (eg, midline lumbosacral lipoma, soft tissue appendage "skin tag" of the midline lumbosacral or pelvic regions) may indicate LUMBAR (lower-body hemangioma and other cutaneous defects; urogenital anomalies, ulceration; malformations of the spinal cord; bony deformities; anorectal malformations, arterial anomalies; and renal anomalies) syndrome. (See 'LUMBAR syndrome' below.)
Imaging studies — Most IH can be diagnosed clinically without additional studies. In the minority of cases where the diagnosis is in question, imaging with ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI) can be helpful [8]. (See 'Differential diagnosis' below.)
Imaging may also be useful in evaluating the extent of a complicated hemangioma, evaluating for other potential anomalies when clinically indicated (eg, PHACE syndrome, LUMBAR syndrome), or following response to therapy, particularly in the case of hepatic hemangiomas. (See "PHACE syndrome" and 'LUMBAR syndrome' below.)
Biopsy — Biopsy and histopathologic examination are necessary if there is any question of malignancy. Clinical findings that may raise suspicion of malignancy include (see "Skin nodules in newborns and infants", section on 'Infantile fibrosarcoma'):
●Lesion fully present at birth
●Hardness to palpation
●Tenderness (unless ulcerated)
●Rapid enlargement
●Deep involvement without any overlying cutaneous clues
●Location on the palm (a frequent location for infantile fibrosarcoma)
INDICATIONS FOR EARLY REFERRAL
General considerations — Depending on the location and morphology of the hemangioma, early referral, ideally within the first four to six weeks of life, to expert centers for additional evaluation may be necessary for infants in whom the diagnosis of IH is in question and for those who have actual or potential organ complications (particularly when the lesion is segmental). Early referral is also indicated for infants for whom systemic therapy is being considered [9]. (See "Infantile hemangiomas: Management", section on 'Risk stratification and indications for referral/intervention'.)
The Infantile Hemangioma Referral Score (IHReS) tool has been developed to help primary care clinicians identify problematic hemangiomas that should be referred to expert centers [10]. (See "Infantile hemangiomas: Management", section on 'The Infantile Hemangioma Referral Score'.)
Special situations
Periorbital hemangiomas — Periorbital hemangiomas may compromise normal visual development (picture 2). In concerning cases (eg, hemangiomas obstructing vision), early examination by an ophthalmologist familiar with the evaluation and treatment of periorbital hemangiomas is mandatory [11]. Hemangiomas that are located on the upper eyelid, >1 cm, and have a deep component are at greatest risk of astigmatism and amblyopia [12].
The management of periorbital hemangiomas is discussed separately. (See "Infantile hemangiomas: Management".)
Segmental hemangiomas — Segmental hemangiomas are not focal or round, are usually plaque like, and demonstrate linear and/or geographic patterning (picture 3) [13,14]. They may also have a morphology similar to infantile hemangiomas with minimal or arrested growth (IH-MAG).
Segmental hemangiomas of the face or scalp may be associated with PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome [14], and those overlying the lumbosacral spine or pelvis may be associated with LUMBAR (lower-body hemangioma and other cutaneous defects; urogenital anomalies, ulceration; malformations of the spinal cord; bony deformities; anorectal malformations, arterial anomalies; and renal anomalies) syndrome and should be evaluated accordingly. (See "PHACE syndrome" and 'LUMBAR syndrome' below.)
Hemangiomas with beard distribution — Infants with segmental, bilateral, cervicofacial or mandibular hemangiomas in a "beard" distribution (picture 1) should be clinically monitored for signs of airway involvement (eg, progressive hoarseness, stridor) [15]. The possibility of PHACE syndrome should also be considered in these patients. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications", section on 'Complications'.)
PHACE syndrome — Infants with large (>5 cm in diameter) segmental hemangiomas, particularly when located on the face or scalp, are at risk for PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome (table 1 and picture 4) [16-18]. These infants should undergo careful cutaneous, ophthalmologic, cardiovascular, neurovascular, and neurologic evaluations [19,20]. The clinical features, diagnosis, evaluation, and management of PHACE syndrome are discussed separately. (See "PHACE syndrome".)
LUMBAR syndrome — LUMBAR (lower-body hemangioma and other cutaneous defects; urogenital anomalies, ulceration; malformations of the spinal cord; bony deformities; anorectal malformations, arterial anomalies; and renal anomalies) syndrome defines the association of segmental hemangiomas over the lower half of the body (picture 5) with regional underlying anomalies [21-29]. LUMBAR syndrome is considered the "lower half of the body" counterpart to PHACE syndrome.
●Diagnostic criteria – Based on expert consensus, diagnostic criteria for LUMBAR syndrome include [30]:
•A segmental IH of the lumbosacral, sacrococcygeal, and/or pelvic cutaneous regions (required)
•At least one of the following:
-Urogenital anomaly
-Spinal cord malformations (eg, tethered cord, spinal lipoma, intraspinal hemangioma)
-Bone anomaly of the sacrococcygeal spine
-Anorectal malformations (eg, imperforate anus, anal atresia, congenital fistulas)
-Urogenital malformations
-Kidney malformations
-Anomaly of the aortic, renal, mesenteric, iliac, femoral, popliteal, tibial, or peroneal arteries
●Imaging studies – Imaging studies should be performed in all infants or older children with a segmental hemangioma over the lumbosacral spine.
•Ultrasonography – Spinal ultrasound may be used for the initial screening of spinal cord malformations in infants <4 months if expertise in pediatric ultrasonography is available and if there are no clinical findings or symptoms that indicate the need for early MRI evaluation [22,23,25,31]. However, ultrasonography may not detect more subtle anomalies (eg, dermal sinus tracts) [30]. Moreover, after the fourth month of life, with progressive ossification of the spine, the quality of ultrasound decreases, and spinal MRI is required for accurate diagnosis.
In a cohort study that included 48 infants with localized or segmental lumbosacral hemangiomas, spinal abnormalities were detected by spinal ultrasonography in 7 of 26 infants (26 percent) [31]. In contrast, MRI detected a spinal abnormality in 21 of 48 infants (44 percent).
•MRI – MRI of the lumbar spine is the most sensitive means to definitively diagnose spinal anomalies in patients with lumbosacral IH. MRI can be delayed until the age of four to six months in infants without high-risk cutaneous findings and in the absence of concerns for spinal dysraphism, and ultrasonography can be used as the initial screening test. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management".)
MRI screening of patients with midline hemangiomas in the lumbosacral area is supported by the results of a multicenter prospective cohort study [31]. In this study, MRI detected spinal anomalies in 21 out of 48 infants (44 percent) with localized or segmental lumbosacral hemangiomas that were ≥2.5 cm in size (risk ratio [RR] 640, 95% CI 404-954). The study did not evaluate imaging in patients with smaller lesions, and it is unclear whether these results translate to patients with small localized hemangiomas.
Segmental hemangiomas with minimal or arrested growth — IH-MAG are an uncommon variant of IH, presenting initially as ill-defined, erythematous patches with multiple fine and coarse telangiectasias, venules, and perilesional blanching [32,33] (see "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications", section on 'Infantile hemangiomas with minimal or arrested growth'). Segmental IH-MAG may warrant further investigation for internal organ involvement to exclude PHACE syndrome or LUMBAR syndrome [34,35]. (See "PHACE syndrome" and 'LUMBAR syndrome' above.)
Multiple cutaneous hemangiomas — Approximately 30 percent of infants have more than one hemangioma, but only 3 percent have six or more lesions [36]. Multifocal cutaneous hemangiomas at risk for concomitant visceral hemangiomas are defined as ≥5 small localized lesions. There is general consensus among experts that infants presenting with multiple cutaneous hemangiomas should undergo imaging evaluation for hepatic hemangiomas [37]. (See 'Hepatic hemangiomas' below.)
Large hemangiomas — Whether large hemangiomas (>5 cm) are associated with an increased risk of hepatic hemangiomas is uncertain [38-40]. Although two small retrospective studies suggested an increased risk for hepatic hemangiomas in infants with large hemangiomas [38,39], in a subsequent prospective study of 60 infants with at least one hemangioma >30 cm2, none had an hepatic hemangioma [40].
Thus, infants with large hemangiomas do not need to be routinely screened for hepatic hemangiomas purely based on lesion size. However, if signs or symptoms that suggest hepatic hemangiomas (poor growth or feeding, tachypnea, cardiac murmur, abdominal distension, or hepatomegaly) are present, referral for evaluation and monitoring is warranted [37]. (See 'Hepatic hemangiomas' below.)
Hepatic hemangiomas
Overview — In infants with multiple cutaneous hemangiomas, the liver is the extracutaneous site most frequently involved, whereas involvement of other sites (eg, the gastrointestinal tract, the brain) is uncommon. Hepatic hemangiomas most often occur as multifocal or, rarely, diffuse lesions [37,41].
●Single focal hepatic vascular lesions are most often not true IH but instead most commonly represent rapidly involuting congenital hemangioma (RICH), which are fully developed at birth and are occasionally detected prenatally by routine ultrasound [37,41]. Like their cutaneous counterpart, they typically rapidly involute after birth, with their size reduced by approximately 80 percent by the age of 12 or 13 months [37]. (See "Congenital hemangiomas: Rapidly involuting congenital hemangioma (RICH), noninvoluting congenital hemangioma (NICH), and partially involuting congenital hemangioma (PICH)", section on 'Hepatic rapidly involuting congenital hemangiomas'.)
●Multifocal hepatic hemangiomas are usually associated with multiple cutaneous hemangiomas and are generally detected by screening or routine abdominal ultrasound examination (see 'Screening' below). Multifocal lesions increase in size throughout the proliferative phase (between the neonatal period and the age of approximately six months) and then gradually involute. Also similar to cutaneous IH, involution is often complete by the age of four to five years on average. During the proliferative phase, due to increased arteriovenous shunting, infants may rarely develop signs of high-output cardiac failure and/or consumptive hypothyroidism due to increased expression of type 3 iodothyronine deiodinase, which inactivates the thyroid hormone.
●Diffuse hepatic hemangiomas are characterized by a nearly complete replacement of the liver parenchyma with hemangioma tissue, leading to serious complications with increased mortality risk, including [42]:
•High volume arteriovenous shunting and cardiac failure
•Bleeding and abdominal compartment syndrome
•Liver failure
Screening — Doppler ultrasound of the liver is the preferred imaging at initial presentation. Small hepatic hemangiomas (<3 cm) typically appear as uniformly hypo- or hyperechoic masses, while larger lesions may contain calcifications, cystic spaces, and sclerotic areas [37]. If the diagnosis is unclear, liver MRI study with contrast and dynamic acquisition pattern and/or liver biopsy can be considered.
●It is generally recommended that infants <6 months with ≥5 cutaneous hemangiomas undergo early evaluation with abdominal ultrasound and be monitored clinically [43-45].
This recommendation is supported by a multicenter study of 151 infants with ≥5 hemangiomas in which 24 (16 percent) had solitary or multiple hepatic hemangiomas and 2 (1.3 percent) had airway or gastrointestinal hemangiomas, while none of the children with ≤4 cutaneous hemangiomas had visceral lesions [46]. Only one child with hepatic hemangioma was symptomatic with hepatomegaly and high-output congestive heart failure and required treatment with propranolol and oral corticosteroids.
●Infants with <5 cutaneous hemangiomas do not require further visceral evaluation or monitoring if findings on physical examination are otherwise normal [47].
●Infants with <5 cutaneous hemangiomas who present with hepatomegaly and/or symptoms of cardiac failure (eg, tachypnea, poor feeding, lethargy) should be evaluated for hepatic hemangiomas regardless.
In a retrospective single-center tertiary referral study including 843 infants (median age six months) with multiple (83 percent) or solitary cutaneous hemangiomas, 71 of 381 infants who were screened by ultrasound (19 percent) had hepatic hemangiomas [48]. Of patients with hepatic hemangioma, approximately one-third had <5 cutaneous hemangiomas. Eight of 843 patients (<1 percent) required treatment for cardiac failure, and six required treatment for hypothyroidism. Six of these 13 patients requiring treatment had <5 cutaneous hemangiomas. All infants treated for cardiac failure were symptomatic at first presentation.
●Infants with diffuse hepatic hemangiomas or multifocal hepatic hemangiomas with or without clinical symptoms of hypothyroidism should also be screened for hypothyroidism. Hepatic hemangiomas can cause consumption hypothyroidism through the production of type 3 iodothyronine deiodinase, which is a thyroid-deactivating enzyme [49,50].
Monitoring — Expert consensus-based guidelines for monitoring infantile hepatic hemangiomas recommend [37,42]:
●Liver ultrasound at progressively longer intervals, with an initial two-week interval, adding two weeks to the interval after each stable evaluation. However, the frequency of monitoring may be individualized based on the degree of liver involvement and whether treatment is implemented.
●Continue monitoring until hemangioma involution is well underway.
●Diffuse hepatic IH at higher risk of complications and mortality require more frequent monitoring and a longer follow-up period.
●Thyroid function tests (thyroid-stimulating hormone [TSH] and free thyroxine [T4]) should be obtained at the time of diagnosis and then repeated monthly in diffuse and multifocal disease at least until the age of six months (approximately end of proliferation period).
●Echocardiogram should be considered if there are signs of cardiac failure or ultrasonographic evidence of shunting or massive flow (enlarged hepatic veins).
DIFFERENTIAL DIAGNOSIS —
The diagnosis of IH can be made based on history and physical examination in the vast majority of cases (see 'Diagnosis' above). Cases in which the differential diagnosis may be difficult include [51]:
●Cutaneous hemangiomas
•Capillary malformation – In approximately one-third of cases, IH is present at birth as a macular, telangiectatic patch ("nascent IH") (picture 6). While this form and the less common infantile hemangiomas with minimal or arrested growth (IH-MAG) (picture 7) are similar in appearance to a capillary malformation (ie, port wine birthmark), capillary malformations tend to be solidly red and well demarcated compared with IH [21]. Hemangiomas with this presentation often have surrounding pallor representing vasoconstriction, which can help to differentiate them from capillary malformations early on. In addition, in contrast with capillary malformations, hemangiomas quickly begin to develop small vascular blebs, become raised, and may show signs of ulceration. (See "Capillary malformations (port wine birthmarks) and associated syndromes".)
•Congenital hemangiomas and vascular malformations – Large vascular lesions that are congenital (ie, "fully developed" at birth) are very unlikely to be true IH, which are characterized by absence or minimal presence at birth followed by proliferation after birth. These include rapidly involuting congenital hemangioma (RICH) or noninvoluting congenital hemangioma (NICH) (picture 8A-B), other benign and malignant vascular tumors, and vascular malformations, diagnoses that can often be made clinically by a specialist familiar with such entities [21,52,53]. (See "Congenital hemangiomas: Rapidly involuting congenital hemangioma (RICH), noninvoluting congenital hemangioma (NICH), and partially involuting congenital hemangioma (PICH)" and "Venous malformations".)
•Kaposiform hemangioendothelioma and tufted hemangioma – Rapidly proliferating, violaceous tumors in the setting of the Kasabach-Merritt phenomenon are not IH but one of two other histologically benign, but sometimes aggressive, vascular tumors: kaposiform hemangioendothelioma (most commonly (picture 9)) or tufted angioma (picture 10). (See "Tufted angioma, kaposiform hemangioendothelioma (KHE), and Kasabach-Merritt phenomenon (KMP)".)
•Subcutaneous tumors – Deep subcutaneous tumors, particularly when no overlying skin changes are present to assist with diagnosis, should be suspect, as should any vascular lesion with an atypical clinical appearance or unusual behavior. Although imaging may be helpful, tissue biopsy is generally necessary in concerning cases in order to exclude malignancy. (See "Skin nodules in newborns and infants".)
•Pyogenic granuloma – Pyogenic granuloma is typically a small (often <1 cm) acquired benign vascular tumor of skin and mucosa characterized by rapid growth and a friable surface that easily bleeds (picture 11). Pyogenic granuloma typically develops on the face or upper trunk in preschool- or school-aged children. Congenital disseminated pyogenic granuloma is a rare, aggressive, multisystemic disorder that is in the differential diagnosis of multiple cutaneous vascular lesions present at birth [54]. Skin lesions are often characterized by friability, necrosis, and bleeding; show early proliferation; but then slowly involute by late infancy or early childhood. The brain is the most common extracutaneous site to be affected in congenital disseminated pyogenic granuloma and can result in high morbidity due to hemorrhage. The diagnosis can be made with a lesion biopsy. (See "Pyogenic granuloma (lobular capillary hemangioma)".)
•Other lesions – Other cutaneous lesions that can occasionally mimic IH include plexiform neurofibroma, infantile fibrosarcoma, dermatofibrosarcoma protuberans, rhabdomyosarcoma, nasal glioma, dermoid cysts, and infantile myofibroma [7,51,55]. These lesions generally have a distinct clinical and histologic appearance. (See "Skin nodules in newborns and infants".)
●Hepatic infantile hemangiomas
•Congenital hemangiomas – Focal hepatic hemangiomas are most often RICH or, rarely, NICH. They do not have associated skin lesions, are generally asymptomatic (except hepatomegaly for large lesions), and show no signs of enlargement after birth. Hepatic RICH, like their cutaneous counterpart, tend to spontaneously regress in the first 12 to 14 months of life, while NICH do not change significantly in size over time [37]. (See "Congenital hemangiomas: Rapidly involuting congenital hemangioma (RICH), noninvoluting congenital hemangioma (NICH), and partially involuting congenital hemangioma (PICH)", section on 'Hepatic rapidly involuting congenital hemangiomas'.)
•Other tumors – Hepatic hemangiomas may be very difficult to distinguish from vascular malformations and other benign and malignant infantile liver tumors, including mesenchymal hamartoma, hepatoblastoma, and metastatic neuroblastoma, especially in infants without cutaneous hemangiomas [41,56]. Imaging studies and biopsy for histopathologic examination are required for accurate diagnosis. (See "Fetal abdomen: Differential diagnosis of abnormal echogenicity and calcification", section on 'Mesenchymal hamartoma' and "Overview of hepatoblastoma" and "Clinical presentation, diagnosis, and staging evaluation of neuroblastoma".)
ONLINE RESOURCES —
Information on IH for patients and families can be found online at The Society for Pediatric Dermatology and the Hemangioma Investigator Group.
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Infantile vascular tumors, including infantile hemangiomas, congenital hemangiomas, and kaposiform hemangioendothelioma".)
SUMMARY AND RECOMMENDATIONS
●Diagnosis – In most cases, the diagnosis of an infantile hemangioma (IH) can be established clinically based on history and physical examination. Deeper subcutaneous lesions without overlying skin change may be difficult to distinguish from vascular malformations or other tumors and may require imaging studies and/or a biopsy for histopathologic examination. (See 'Diagnosis' above.)
●Indications for early referral – The Infantile Hemangioma Referral Score (IHReS) tool has been developed to help primary care physicians identify problematic IH that should be referred to expert centers. Early referral, ideally within the first four to six weeks of life, is indicated in the following circumstances:
•The diagnosis is in question.
•Infants with actual or potential organ complications.
•Infants with IH requiring systemic treatment.
●Special situations – Examples of specific indications for early referral include:
•Periorbital hemangiomas – Infants with periorbital hemangiomas at risk for visual compromise (picture 2) should be referred to an ophthalmologist and/or other specialist familiar with the evaluation and treatment of periorbital IH. (See 'Periorbital hemangiomas' above.)
•Segmental hemangiomas
-Face and scalp – Infants with large (>5 cm in diameter) segmental IH, particularly when located on the face or scalp (picture 4), are at risk for PHACE (posterior fossa anomalies, hemangioma, arterial anomalies, cardiac anomalies, and eye anomalies) syndrome (table 1) and should undergo careful cutaneous, ophthalmologic, cardiac, and neurologic evaluations. (See "PHACE syndrome".)
-Lower body – Infants with segmental IH over the lumbosacral or pelvic regions (picture 5) should be evaluated with MRI for underlying spinal dysraphism and other anomalies that define LUMBAR (lower-body hemangioma and other cutaneous defects; urogenital anomalies, ulceration; malformations of the spinal cord; bony deformities; anorectal malformations, arterial anomalies; and renal anomalies) syndrome. (See 'LUMBAR syndrome' above.)
•Multiple hemangiomas – Infants younger than six months with ≥5 small cutaneous IH should undergo ultrasonography of the abdomen for potential liver hemangiomas and be monitored clinically. Infants with <5 cutaneous hemangiomas who present with hepatomegaly and/or symptoms of cardiac failure should be evaluated for hepatic hemangiomas regardless. (See 'Multiple cutaneous hemangiomas' above and 'Hepatic hemangiomas' above.)
