Viewpoints in dermatology • Correspondence


Scoring the proliferative activity of haemangioma of
infancy: state of the art
doi: 10.1111/j.1365-2230.2011.04323.x
We read with great interest the article by Janmohomed
et al.1 in a recent issue of this journal, in which they
proposed a new scoring system, the Haemangioma Activity
Score (HAS), to evaluate and monitor the activity and
treatment outcome of infantile haemangiomas (IH).
Although greatly needed, such a standard instrument for
uniform objective scoring is still not available, and beyond
doubt, the contribution of Janmohamed et al. adds much to
its development. Nevertheless, we suggest that the proposed system has two shortcomings, related to colour and
consistency, which might impede correct assessment of
clinical improvement.
Firstly, the newly proposed system scores each colour
present in the lesion, and the total score is then divided by
the number of items scored. Scoring the colour only,
without taking into account the size of the area with this
colour, records the presence of regression, but does not
reflect its extent. This score might be useful, under certain
conditions, for assessment at a single time point, but is
imprecise for multiple periodic assessments. In addition, the
final stage of IH, either post-treatment or when left to
natural regression, commonly presents with several telangiectatic vessels on a grey or skin-coloured background.
These remaining vessels still do not represent complete
regression, but cannot be associated with any of the colour
categories proposed in the system.
Secondly, actively growing, proliferating IH are very
tense on palpation, and a change in the consistency of the
superficial area of IH from tense to soft is usually the first
indication of treatment efficacy. This change in consistency
may or may not correlate with colour changes. Thus,
although it is not the most important sign of treatment
response, change in consistency does represent regression
and, in our opinion, should therefore be included in the
scoring criteria.
Scoring IH is challenging because of interindividual
differences in their behaviour and response to treatment.
Most authors use the subjective visual analogue scale
(VAS), the Global Assessment Scale, or a measurement of
the changes in surface area, volume or thickness of IH.2

The objectivity and, more importantly, the reproducibility
of these methods remain questionable.
The proposed scoring model provides a good evaluation
of activity, but might not be precise enough to reflect
minor changes (Fig. 1). An accurate scoring system is
crucial for the assessment of activity to guide therapeutic



Figure 1 An infantile hemangioma in a 6-month-old girl after (a)
4 and (b) 12 weeks of treatment with topical timolol maleate. The
improvement is obvious by the extension of the areas of regression,
the breaks in the border and the softening of the lesion; however,
the proposed Haemangioma Activity Score would give the same
rating for both time points, indicating no improvement. 

The Author(s)
CED  2012 British Association of Dermatologists • Clinical and Experimental Dermatology, 38, 89–101


but rather an activity score that reflects whether the therapy is working. Sofiiski Boulevard. Consequently. de Waard-van der Conflict of interest: none declared. Bruckner AL.  The Author(s) CED  2012 British Association of Dermatologists • Clinical and Experimental Dermatology. there is no need for scoring the IHs during the later years. consistency cannot be evaluated on photographs. 5Department of Paediatrics. simple and rapid system such as the HAS. Madern GC.5 and at the age of 6 years has a HAS of 0 but with telangiectatic lesions. 89–101 . for example. 36: 715–23. IHs grow very rapidly. 36: 715–23. which are in fact secondary efflorescences. and 6Department of Biostatistics.g. Scoring the proliferative activity of haemangioma of infancy: state of the art.Correspondence decision and evaluation of treatment response. Madern. C. University Medical Center.12056 Semkova and Kazandjieva1 recently commented on the Haemangioma Activity Score (HAS) we developed and reported in a recent issue of Clinical and Experimental Dermatology. Clin Exp Dermatol 2011. In addition.3 F. but we believe that scoring for both IH size and telangiectatic vessels. Division of Paediatric Dermatology. We also encourage others to validate the HAS and. Therefore. Scoring the proliferative activity of haemangioma of infancy: to HAS or not to HAS? Reply from author doi: 10.3. compared to the changes that occur in the first year. C. 38: 89–90. and thus we did not include these items. We are currently planning a large validation study to validate the HAS. We understand these concerns. Therefore. Scoring the proliferative activity of haemangioma of infancy: the Haemangioma Activity Score (HAS). Semkova and Kazandjieva proposed that consistency of the lesion should be taken into account. P. During this long period. R. First. unlike other systems such as the recently published system by Haggstom et al. the presence of ulceration or telangiectatic lesions in regressed IHs that provoke cosmetic distress). Oranje2. meaning that size does not have to be taken into account.oranje@inter. individual IHs do not change greatly per year. Kazandjieva J. Sofia.3. we consider that the proposed HAS needs some minor amendments to satisfactorily reflect meaningful clinical changes with the necessary sensitivity to become a useful clinical tool. de Waard-van der Spek FB. Kazandjieva Department of Dermatology and Venereology. Clin Exp Dermatol 2011. The HAS.4 G. and most of the changes occur in the first year of life. A novel method for calculating the Volume of hemangiomas.2. J. Hop6 and A. and the fact that HAS can be performed on photographs is an extremely important aspect of this method. 2 Berk DR. Accepted for publication 22 November 2011 References 1 Janmohamed SR. 2 Janmohamed SR. if desirable. rapidly growing IHs around the eye are more problematic) or appearance (e. the score will be different in IHs at different time points. there is some overlap. de Waard-van der Spek FB.1 P. and in fact. 38. During this first year.2 Although every system will have its shortcomings. C. Erasmus MC. Our score is not a severity score that tells you whether or not to treat. the Netherlands Email: a. It does not seem relevant that. Accepted for publication 13 September 2012 References 1 Semkova K. Hence. perhaps more importantly. to compare the HAS with other assessments.7 1 Department of Paediatric Surgery. to 90 evaluate the effect of treatment. this system can also be used in research.5 W. is not a necessity for a small. Clin Exp Dermatol 2013. Janmohamed. Berk EJ. a patient at the age of 5 years had IH in regression with a HAS of 0. We deliberately left this out. Maasstadziekenhuis. Havenziekenhuis. Rotterdam.1111/ced. 28: 478–82. the Netherlands. B. 3KinderHaven. Rotterdam. Second. and thus we consider that there is no demand for severity scores. Semkova and J. we believe that the HAS remains a valuable option for scoring the activity of infantile haemangioma (IH). they point out that the HAS does not assess the residual lesions (telangiectatic vessels) and IH size. regression starts. 1 G. After Conflict of interest: none declared. during the first year of life. However.. In that context. The choice of treatment is in our opinion dependent on a number of factors. a scoring system is necessary to (objectively) measure (re)growth or regression and. and 7Department of Dermatology. but we use a different We would like to address two clinically relevant issues raised by Semkova and Kazandjieva. such as change in lesion consistency. 2Department of Paediatrics. Pediatr Dermatol 2011. Rotterdam. de Laat. S. Medical University-Sofia.3 is not very timeconsuming and does not take much time during busy consultations. considered swelling of the IH as an alternative. the Netherlands. Madern GC et al. K. J. such as location (for instance. et al. Bulgaria E-mail: kristina_semkova@yahoo. We saw the effectiveness of the HAS in the early stages of treatment. and this can last for up to 10 years. 4Department of Dermatology and Venereology. the colour and swelling (if present) do change a great deal. Scoring the proliferative activity of haemangioma of infancy: the Haemangioma Activity Score (HAS).