Birthmarks in babies, from stork bites to strawberry marks

Most birthmarks are harmless and many fade on their own. Pink stork bites and blue-grey Mongolian spots are very common and need nothing. Strawberry haemangiomas grow fast in the first months, then slowly shrink, and a few need early treatment. Port wine stains and many cafe au lait spots stay, and some deserve a closer look. Show any new or growing mark to your doctor early, ideally in the first month.

What are the most common birthmarks in newborns?

The most common are pink salmon patches (stork bites) and blue-grey Mongolian spots. In a study of nearly 600 newborns, 83% had a salmon patch and 20% had blue-grey patches.¹

The same study found strawberry haemangiomas in 4.5% of babies by 3 months, small moles in 2.4%, and light brown cafe au lait spots in 2%.¹ Port wine stains were rare, at 0.3%.¹ Birthmarks are not caused by anything the mother ate or did in pregnancy, and not by an eclipse, whatever the elders may say.

What is a stork bite or salmon patch?

A stork bite is a flat pink or red patch on the back of the neck, the eyelids, the forehead between the eyebrows, or the upper lip. Doctors call it naevus simplex. It is the most common birthmark of all.¹

It is made of tiny widened blood vessels in the skin and becomes darker when your baby cries or is hot. Patches on the face usually fade in early childhood. Patches on the back of the neck often stay but are hidden by hair. No treatment is needed.

What is a strawberry haemangioma?

A strawberry haemangioma is a soft, raised, bright red lump made of extra blood vessels. Doctors call it infantile haemangioma. It is the most common benign (non-cancer) tumour of infancy, seen in up to 5% of babies.²

Most are not visible at birth or show only as a pale or faint red mark. They appear in the first weeks and then grow. Deep ones lie under the skin and look bluish, like a soft swelling. Haemangiomas are more common in girls, preterm babies and twins or triplets.³

How fast does a strawberry haemangioma grow?

The fastest growth is between 1 and 3 months of age. Most haemangiomas reach about 80% of their final size by 3 months.⁴

Growth is finished by about 5 months in most babies.² Deep haemangiomas can grow later and for longer.⁴ This early growth is the reason not to "wait and watch" for a year if the mark is in a risky place. By the time many babies reached a specialist, most growth was already over.⁴ Take dated photos every 2 weeks to show your doctor.

Will a strawberry haemangioma go away?

Most shrink slowly over several years, and most cause no harm.⁵ But many leave some lasting change in the skin, such as loose skin, fine visible vessels or a fatty bump.²

The red colour fades first, turning grey or purple, and the lump softens. A small haemangioma on the back or leg can simply be watched. A large one on the face, especially the nose or lip, may leave a mark that bothers the child later. That is why some are treated early.

When does a haemangioma need treatment?

Treatment is needed when a haemangioma can harm sight, breathing or feeding, can ulcerate (break down into a sore), or can leave lasting scars on the face.²

Higher-risk haemangiomas include:² - Near the eye, which can block vision - On the nose, lip or large areas of the face, which can scar - Large facial ones, which need checks for blood vessel problems in the brain and heart - Any that bleed, crust or break down into a sore (ulcer) - In the beard area of the jaw, chin and neck, which can mean one inside the airway⁶ - Five or more on the skin, which can mean some in the liver⁷

The guideline advises referral by about 1 month of age for these.²

Is propranolol safe for haemangioma?

Yes, when started and monitored by a doctor. Propranolol is a heart medicine that also shrinks haemangiomas, and it is now the first choice for those needing treatment.²

In a large trial, 60% of babies on propranolol for 6 months had complete or nearly complete clearance, compared with 4% on a dummy medicine.⁸ Side effects such as low blood sugar, low blood pressure, slow heart rate and wheezing were uncommon, and no more frequent than with the dummy medicine.⁸ Give each dose with or just after a feed, and skip a dose if your baby is unwell and not feeding. Treatment usually lasts at least 6 months and often until about 12 months of age.²

What other treatments are there for haemangioma?

For small, thin, flat haemangiomas, a beta-blocker gel or drops (timolol) rubbed on the skin may be used.²

Laser and surgery are mostly used later, to treat leftover skin changes once the haemangioma has shrunk.² A Cochrane review of 28 trials looked at many treatments, including lasers, beta blockers and steroids.⁵ Please avoid home remedies such as tying thread around the lump or applying caustic pastes. These cause ulcers and scars.

What is a port wine stain?

This is a flat pink, red or purple mark that is there from birth. It is a capillary malformation (a patch of widened small blood vessels), found in about 0.3% of newborns.¹ It does not fade by itself.⁹

It grows in step with the child. Over many years it can darken and become thicker or bumpy.⁹ Pulsed dye laser is the standard treatment, and results may be better when treatment starts at a younger age.⁹ Ask for referral to a dermatologist with laser experience.

What is Sturge-Weber syndrome?

Sturge-Weber syndrome is a rare condition linked to a port wine stain on the face, involving the skin, brain and eyes.¹⁰

It can cause fits, weakness on one side, learning problems and glaucoma (raised pressure in the eye). A baby with a high-risk facial port wine stain, usually on the forehead or upper eyelid, should be seen by a child neurologist and a child eye specialist early, and then followed up.¹⁰ Routine brain scans are not needed in a baby with no fits or nerve symptoms, but may be done in some cases.¹⁰

Are Mongolian spots a bruise?

No. Mongolian spots are flat blue, grey or green-grey patches, most often over the lower back and buttocks. They are not bruises and do not hurt.

They are extremely common in Indian babies. In a study of more than 2300 newborns in Puducherry, 65.9% had them.¹¹ More than 40% had disappeared by age 1.¹¹ Spots that are many, large (over 10 cm), dark, or away from the lower back were more likely to last longer.¹¹ Because they can look like bruises, they are sometimes mistaken for injury.¹² Ask your doctor to note them in your baby's health record, so a new doctor is not confused later.

Are cafe au lait spots something to worry about?

One or two light brown, coffee-with-milk coloured spots are common and usually mean nothing. About 2% of newborns have one.¹

Six or more cafe au lait spots, each larger than 5 mm in a young child, is one of the signs of neurofibromatosis type 1 (NF1), a genetic condition.¹³ Freckles in the armpits or groin are another sign.¹³ If you count 6 or more, see your paediatrician. NF1 is diagnosed from a group of signs or a genetic test, not from one spot.

What about moles that a baby is born with?

Small moles present at birth (congenital melanocytic naevi) are found in about 2.4% of newborns.¹ Most are harmless.

Very large moles, or a mole with many smaller moles around it, need a dermatologist's review. For any mole, take a photo every few months. Show your doctor if it changes shape or colour quickly, bleeds, or itches.

Can birthmarks be removed with creams or home remedies?

No cream fades a stork bite, Mongolian spot or port wine stain. The good news is that the first two usually fade on their own.

Medical treatments that work, such as propranolol or laser, are chosen for the right mark at the right age.^2,9 Bleaching creams, lemon, turmeric pastes and steroid creams bought without a prescription can burn or thin a baby's skin.

When should I take my baby to a doctor about a birthmark?

See a doctor within days, not weeks, if: - A red lump is growing fast, especially in the first 3 months⁴ - Any haemangioma is near the eye, on the nose or lip, or in the beard area^2,6 - A haemangioma turns dark, crusts, bleeds or becomes a sore (ulcer)² - Your baby has 5 or more haemangiomas⁷ - There is a port wine stain on the forehead or eyelid¹⁰ - You count 6 or more cafe au lait spots¹³

Go to hospital at once if a baby with a haemangioma on the jaw or neck has noisy breathing, or if a baby on propranolol is sweaty, floppy or not feeding.^2,8