Neonatal skin disorders and birthmarks — formative SAQs

SAQ 1 — A rapidly growing periocular haemangioma (20 marks, 30 minutes)

Stem. A 6-week-old girl is brought by her parents because a "red spot" beside the left eye, first noted at two weeks of age, has grown steadily into a bright-red, lobulated plaque on the upper eyelid that is now beginning to push the eyelid downward. She is feeding and growing normally. Outline your assessment, immediate management, counselling, and follow-up. [4]

Model answer

Problem representation. [4]

A 6-week-old with a proliferating superficial infantile haemangioma of the left upper eyelid — a periocular haemangioma at high risk of visual compromise that warrants urgent intervention. [4]

Assessment. [1]

Confirm the lesion is an infantile haemangioma: absent at birth, proliferative phase, bright-red lobulated "strawberry" plaque. [1] Assess specifically for visual threat — does it block the visual axis (deprivation amblyopia) or distort the globe (astigmatism)? Check for proptosis or anisometropia. [4] Count all cutaneous lesions (five or more triggers hepatic screening) and examine the beard area for airway risk, then measure and photograph the lesion as a baseline. [4]

Immediate management. [4]

Refer to ophthalmology within days for refractive and visual-axis assessment — this is the time-critical step. [4] Start oral propranolol in divided doses titrated to the standard weight-based target, the first-line systemic therapy for a periocular haemangioma, continued through proliferation. [4] [5] Baseline heart rate, blood pressure and feeding assessment precede initiation, and the contraindications of clinically significant bradycardia, heart block and reactive airway disease are excluded. [5] Counsel parents on the silent-hypoglycaemia risk with explicit sick-day rules: hold the dose and seek review if the infant is off feeds or unwell. [5]

Counselling. [4]

Explain that the lesion will continue to grow for some months and then involute over years, and that propranolol arrests proliferation to protect vision. [4] Describe the expected course and side effects in writing and arrange a clear safety-net and contact pathway. [5]

Follow-up. [5]

Ophthalmology review of refraction and the visual axis continues repeatedly through proliferation. [4] Monitor propranolol tolerability and wean rather than stop abruptly at the end of proliferation, and refer any residual skin change for later laser or surgical review. [5]