Worrisome Hemangiomas Require Intervention


CORONADO, CALIF. — "Some of the most painful and troublesome hemangiomas I've taken care of are those in the genital area," Dr. Sheila Fallon Friedlander said at the annual meeting of the Pacific Dermatologic Association. "They are extremely painful and often require intervention."

Other worrisome hemangiomas include those which cause visual obstruction, airway obstruction, deformation, and friction, said Dr. Friedlander, section chief of dermatology at Rady Children's Hospital-San Diego.

She added that segmental or patterned hemangiomas are likely to become problematic, and that multiple lesions raise the issue of possible visceral involvement.

Other worrisome hemangiomas include those which appear in the lumbosacral area. "That could indicate tethered spinal cord and spinal dysraphism, so I worry about that," Dr. Friedlander said. "There have also been several articles describing pelvis or sacral syndrome: anomalies of the pelvic or genitourinary organs if you have a hemangioma that's plaquelike and large in the anogenital area."

The prevalence of infantile hemangiomas is not clear, but it appears that 1%–2% of newborns will have such a lesion. When children are followed out to 1 year of age, the prevalence is 10%–12%. "Fortunately for them and for us, most of these lesions never cause a problem," said Dr. Friedlander.

About one-third of hemangiomas are present at birth but most develop during the first few months of life. Sometimes the first sign is a white vasoconstricted area of skin. "But over time the area will become red and then become protuberant," she said. "If you watch it long enough it will grow for the first 6–12 months of life, it will stop growing, and it will eventually improve. Fortunately, that's good news. So remember: You can be consulted about a lesion in an infant that just looks like a vasoconstricted or white area, but it may be an early hemangioma."

Dr. Friedlander noted that traditionally experts have stated "30% of hemangiomas fade away by age 3, 70% by age 7, and 90% by age 9." When the affected child reaches age 4 or 5, "we get a sense of those lesions which are going to go and those which are going to stay," she said. "The standard in our office is to tell families to definitely return around 4 years of age before [the child starts] kindergarten to see what it looks like."

Research on the etiology of hemangiomas continues to evolve. To date, high-risk patients include those with large facial plaquelike hemangiomas, preemies, twins, and infants born to mothers with abnormalities in the placenta.

Large plaquelike lesions, particularly of the face, warrant a careful physical exam, eye exam, an echocardiogram, and often an MRI/magnetic resonance angiography of the head.

The goal of treatment is to prevent function-threatening events such as disfigurement and to minimize psychosocial distress, "but you don't want to do something very aggressive early on that's going to lead to scarring which was unnecessary," Dr. Friedlander said.

Systemic prednisone at a dose of 2–5 mg/kg per day is indicated for patients with symptomatic troublesome lesions. Dr. Friedlander said that flavored agents "taste a lot better than regular generics." She uses Orapred syrup (prednisolone sodium phosphate) which comes in a concentration of 15 mg/5 mL. She usually starts with a dose of 2 mg/kg per day as one early morning dose with food.

Patients usually require months rather than weeks of therapy. Approximately 30% of lesions will shrink, another 40% will stop growing but may not shrink, and the remaining 30% may not respond, even if the steroid dose is increased. "It is important to monitor blood pressure and growth during treatment," she said. "At our center, we treat these children with H2 blockers to prevent gastric irritation, and make certain that they are aware of the risks of severe varicella infection if they are exposed to this virus. If that occurs, they should receive oral acyclovir."

Other treatment options include topical class 1 steroids such as clobetasol for thin lesions, and intralesional corticosteroids such as triamcinolone acetonide. "These can be very useful for discreet lesions but you need to be careful around the eyes," she emphasized. "There have been some reports of central retinal or ophthalmic artery occlusion and blindness. For that reason I refer to ophthalmology if periorbital injection is required."

Laser treatment of infantile hemangiomas is controversial, but she said that it makes a "tremendous difference" in children who develop ulcerated lesions in the groin area. "These kids are in horrendous pain," she said. "For many of them, one or two laser treatments will expedite healing such that they are no longer in pain."


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