When Does a Rapidly Involuting Congenital Hemangioma (RICH) Require Treatment?

Mar 27
2025

Rapidly involuting congenital hemangiomas (RICHs) are a unique type of vascular tumor that generally appear at birth or shortly thereafter. Thankfully, the majority of RICHs resolve on their own without any complications. However, there are cases where medical intervention is necessary to address concerns that these lesions may present. Understanding when treatment is required can be crucial for both pediatricians and parents alike.

What Are Rapidly Involuting Congenital Hemangiomas?

RICHs are characterized by fast growth during the first months of life, followed by a phase of involution during which they shrink and eventually disappear.

A recent study published in the April 2024 Journal of the American Academy of Dermatology revealed that the involution of RICHs is not a linear process. They found, “for the first time, that the involution of RICH is not linear and, instead, occurs rapidly during the first few months of life. All RICHs had clinically visible regression within 4 weeks after birth. Our results further support the opinion that most RICH should be left untreated in accordance with the principle of ‘benign neglect.’”

The Principle of Benign Neglect

The prevailing thought among dermatology and birthmark professionals is that most RICHs do not require treatment, following the principle of “benign neglect.” This means that careful observation without immediate intervention is usually the best approach, as many RICHs will resolve spontaneously. However, it’s important to remain vigilant, as some cases may lead to complications that necessitate referral to a specialist.

In the JAAD study referenced above, researchers also “found residual skin changes in 82.6% of patients, with lesions involving the head/face being substantially more likely to leave significant or severe residual skin changes than in other sites. Significant or severe skin changes on exposed body areas could be a great burden for many children and their parents.”

When Does a RICH Warrant Treatment?

Some conditions may warrant treatment, including:

1. Chronic Ulceration: If the hemangioma becomes ulcerated, exposing the skin and leading to potential infection, treatment may be required to manage these complications effectively.
2. Significant Residual Skin Changes: Significant skin changes in visible areas can sometimes be a source of emotional distress or social stigma for children, warranting consideration for interventions such as laser therapy.
3. Functional Impairment: If the hemangioma affects the function of surrounding tissues (for instance, if it obstructs vision, breathing or other critical functions), medical intervention may become urgent.
4. Cosmetic Concerns: While cosmetic concerns should not always dictate treatment, the psychological impact on a child who has noticeable skin changes can be substantial. In such cases, discussions about treatment options may be appropriate.
5. Location Matters: Lesions located on exposed areas, such as the face, may bear greater risks of residual changes after involution, and careful monitoring is necessary to assess whether treatment options are warranted.

NYC Rapidly Involuting Congenital Hemangioma Removal

While RICHs often resolve without intervention, attentive monitoring is essential for cases that deviate from the norm. Understanding when to seek treatment is crucial in ensuring that complications are addressed promptly, and support is provided for the child and their family. If you’re concerned about a rapidly involuting congenital hemangioma in your child, contact The Vascular Birthmark Center of New York today.