Red, white and brown: Defining characteristics of common birthmarks will determine type and timing of treatment

Speaking February 4 at the 69th Annual Meeting of the American Academy of Dermatology (Academy), dermatologist Sheila Fallon Friedlander, MD, FAAD, professor of clinical pediatrics and medicine at the University of California San Diego (UCSD) and section chief of pediatric dermatology at Rady Children's Hospital in San Diego, discussed which birthmarks should be treated in infancy and the most effective treatments for red, white and brown birthmarks.

"There are several different types of birthmarks, so it is important to determine the type of birthmark before considering any possible treatments," said Dr. Friedlander. "Most birthmarks pose no risks to infants and are best left untreated, but some can grow and potentially cause complications, particularly if they occur around the eyes, lips, nose or groin area. In addition, any lesion that has the potential to ulcerate should be monitored."

Infantile Hemangiomas: When Red Birthmarks Raise a Red Flag

The most common types of red birthmarks are known as infantile hemangiomas, which typically appear on the skin at birth or shortly thereafter as small strawberry-shaped bumps or flat spots. Infantile hemangiomas grow during the first two to six months of life, after which time they typically stop growing. Dermatologists can generally pinpoint how much skin will be affected by this type of birthmark by the time an infant is three or four months old. Dr. Friedlander emphasized that most infantile hemangiomas do not pose a problem to infants, but dermatologists can often provide useful information to families regarding the potential for problems by assessing the location of the birthmark and the degree to which it grows during the first few months of life.

"Over time, most infantile hemangiomas will disappear on their own, but there are instances where dermatologists will recommend treatment," said Dr. Friedlander. "For example, if an infantile hemangioma occurs around the eyes, it can obstruct and prevent normal visual development if left untreated, or, if they occur in the groin area, they can become inflamed and then cause pain to the child. Depending on their size, some facial birthmarks may leave behind a scar or saggy skin after they disappear. That is why it is often important for parents to consult a dermatologist as soon as their baby develops a birthmark, so it can be properly evaluated to determine if treatment is necessary."

Dr. Friedlander added that the presence of a large facial hemangioma is sometimes the first sign of a more serious disorder termed PHACES. In this disorder, a hemangioma occurs on the face which is broader and more likely to pose a problem that requires medical intervention. Because PHACES may be a sign of an underlying abnormality, including heart defects, eye abnormalities, blood vessel or brain problems, it also requires specialized evaluation and imaging.

There are times infantile hemangiomas require treatment, and if they do, there are several treatment options available. While systemic steroids and intralesional steroid therapy -- where the treatment is injected directly in the birthmark -- have been widely used, they may cause side effects that a dermatologist will need to discuss with parents prior to treatment. A recent breakthrough in the treatment of hemangiomas is the use of propranolol, a drug used to treat high blood pressure. This medication has recently been found to be very effective for preventing growth of and actually shrinking these lesions, but this medication also has potential side effects that can be serious and need to be monitored closely. Other effective treatments being used are topical medications and laser therapy.

Another common vascular birthmark that may require treatment is a port- wine stain. Unlike infantile hemangiomas, port-wine stains will slowly darken and thicken over time and will not resolve on their own. Characterized by a flat appearance with a pink, red, or purplish discoloration, port-wine stains commonly appear on the face and can affect a child physically and emotionally. Dr. Friedlander explained that port-wine stains can be associated with eye problems, including glaucoma, and seizure disorders. For this reason, infants with port-wine stains need to be evaluated in a timely manner.

"Because port-wine stains grow and thicken over time and will not go away, many parents opt to treat them early when children are small," said Dr. Friedlander. "While dermatologists have been using pulsed-dye lasers for decades to treat these types of birthmarks, different forms of laser therapy that penetrate more deeply -- such as the Nd:YAG laser and the alexandrite long-pulsed laser -- also are now being used with much success." Dr. Friedlander noted that laser therapy is usually started within the first six to 12 months of life, and approximately six to eight treatments are needed to obtain optimal results.

Dr. Friedlander added that new research is investigating the use of an oral medication, rapamycin, for treating port-wine stains in conjunction with laser therapy.

"This is an exciting potential treatment because it could help prevent the recurrence of the birthmarks that initially fade, but sometimes recur, when treated with the pulsed-dye laser," said Dr. Friedlander.

White Spots: A Cause for Concern?

While far less commonly noted at birth than red birthmarks, white birthmarks can appear as white spots in a raised or flat pattern on the skin. Dr. Friedlander noted that although white birthmarks are generally harmless, they can sometimes result in a permanent loss of pigmentation in the affected area. Some can grow and removal may be a consideration.

"Generally, a few white spots that are flat are not cause for concern. However, multiple white spots or lesions that are elevated or thick need to be evaluated by a dermatologist," said Dr. Friedlander, who added that removal by excision or the CO2 laser is sometimes used when white birthmarks require medical intervention, which is very rare.

Brown Birthmarks Linked to Melanoma

One type of brown mole that is present at birth is the congenital nevus. This type of brown birthmark results from an increased number of melanocyte cells (the pigment-producing cells of the body) and can develop into melanoma -- the deadliest form of skin cancer. Most moles present at birth, particularly the small ones, have a very, very small risk of converting into melanoma. Dr. Friedlander explained that approximately 3 to 6 percent of very large congenital nevi can possibly develop a melanoma, but this percentage is quite controversial. Most moles never get bigger than two or three inches in diameter, but some larger lesions that grow and darken are hard to follow and pose a higher risk than smaller lesions. As such, Dr. Friedlander recommended that those moles deemed a higher risk for developing into melanoma should be followed closely or considered for surgical removal if possible, by a dermatologist.

Another brown birthmark that may be worrisome for families is a café au lait birthmark. The term café au lait is French for "coffee with milk," which refers to the light brown color of this flat type of birthmark. While these birthmarks may not be appealing visually, Dr. Friedlander added that they do not pose a medical concern unless there are multiple café au lait birthmarks or a very large spot is present.

"If a patient has multiple café au lait birthmarks, they need to be evaluated by a dermatologist for other associated conditions. In particular, the health care provider needs to rule out neurofibromatosis -- a genetically inherited disorder in which the nerve tissues grow tumors," said Dr. Friedlander. "For patients who want to treat a cosmetically troublesome facial café au lait birthmark, various lasers exist which can be useful."

Dr. Friedlander encouraged concerned parents of infants or children with birthmarks to see a dermatologist to rule out any underlying conditions or medical problems that could be linked to them.