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Hemangiomas: Closely Monitor, Classify, and Look Beyond Skin


 

TORONTO — Closely observe a baby with a hemangioma in the first few weeks to months to monitor for any progression, and be cautious with laser treatment, Dr. Alfons Krol said at the annual conference of the Canadian Dermatology Association.

Knowing whether a malformation is likely to rapidly involute will help to guide management. Lasers, he said, can increase complications and should be reserved for the final stage of a multimodal approach.

Classification is important. A rapidly involuting congenital hemangioma (RICH) can be fully formed at birth. "These things can rapidly disappear. They regress and deflate very rapidly," Dr. Krol said. "I use the cooking analogy of a soufflé that collapses in the center."

Hemangiomas in distal areas such as the fingers and feet tend to involute more rapidly than lesions elsewhere. "This is something that has not been well appreciated in the literature," he said.

Some hemangiomas involute slowly, taking anywhere from 2 to 10 years to spontaneously curl inward. Others are not apparent at birth, and postnatal growth may start at 3–12 months. For example, perineal or lip ulcerations that present shortly after birth almost always turn out to be hemangiomas, said Dr. Krol, director of pediatric dermatology at Oregon Health & Science University, Portland.

Hemangiomas "can be small but of great concern to parents. Make sure parents understand they should report any sudden growth between appointments," he said.

In contrast, noninvoluting congenital hemangiomas (NICH) "behave more like a malformation. They tend to grow with the child and do not involute [Plast. Reconstr. Surg. 2001;107:1647–54]," Dr. Krol said. "The only way to treat them is to remove them with surgery."

Dr. Bernice Krafchik of the Hospital for Sick Children in Toronto asked Dr. Krol if he could tell the difference between a RICH and a NICH.

"They can look similar," he replied. "Basically, one starts off large and never gets better—it grows with the patient. You can say that is a NICH."

The clinical implications of a hemangioma go beyond the skin, and can include the liver, central nervous system, and gastrointestinal tract. "The teaching point here is with the 5-point scoring system," Dr. Krol said. If the score is 4 or greater, 63% have airway involvement and about 40% will require tracheostomy. He recommended starting oral steroids while these patients are on their way to an otolaryngology consultation.

"If patients have multiple hemangiomas—more than five or six present—there is an increased risk of hemangioma in other areas, such as the liver," Dr. Krol said. Scan other areas, including the central nervous system, if the liver is positive, he suggested.

Treatment of hemangiomas includes topical or intralesional steroids for select focal lesions. Oral steroids are indicated for life-threatening or function-threatening lesions, 2–4 mg/kg for 4–8 weeks, with a gradual reduction tapered over 2–3 months.

"Alpha interferon is another option, but there are more side effects," Dr. Krol said. Petrolatum applied daily to the surface can minimize secondary changes, including ulceration, he said.

Pulsed-dye lasers held early promise for treatment of hemangiomas, "but we now understand that if the lesion is destined to have that deep component, lasers are of little benefit. This makes sense because the laser goes superficially," he said.

In one study, 121 patients treated with pulsed-dye laser experienced improved redness on the surface, but there was no difference in complete clearing or resolution for laser group versus observation (Lancet 2002;360:521–7). Skin atrophy and hypopigmentation were significantly higher in the laser treatment group. "So certainly [laser treatment] has the potential to increase complications," Dr. Krol said.

"Lasers are best as part of a multimodal approach to 'mop up' after completion of other therapy," he said. One potential indication is after surgery for debulking of a hemangioma to improve any significant telangiectasia.

There are some surgeons who will approach these hemangiomas early in life, Dr. Krol said "If you have a good surgeon and it's technically feasible, I don't think we have to wait as long as we told patients in the past for surgery," he said. "Children become self-aware around age 3 years, so I use that as a guide."

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