Infantile Hemangiomas

May 2015 | Volume 14 | Issue 5 | Features | 443 | Copyright © May 2015


Shanna Spring MD and Ilona J. Frieden MD

Birthmarks and Vascular Anomalies Center and Division of Pediatric Dermatology, Benioff Children’s Hospital, University of California, San Francisco, CA
University of California, San Francisco, CA and The Hospital for Sick Children, Toronto, ON

kg/d. Patients less than 5 to 6 weeks of age or with medical comorbidities should be considered for a short inpatient stay for propranolol initiation. In the pivotal randomized controlled trial of Hemangeol®, 6 months of treatment was clearly superior to a duration of 3 months.11 Some patients require even longer treatment courses of a year or more. Risk factors for rebound growth with tapering or stopping the medication include deep soft-tissue involvement and segmental distribution.12
Other beta blockers have also been reported to have beneficial effects, though in far smaller numbers. These include atenolol and nadolol. One reason they are being considered is because they do not cross the blood-brain barrier and could mitigate potential CNS effects on sleep and – although unproven – on development.13 A proof of concept study by Pope et al reported greater improvement in patients treated with nadolol vs propranolol but conclusions are limited by the small size of the study.14 Corticosteroids remain a therapeutic option when other treatments are contraindicated. However, they are no longer first-line therapy due to their relative lack of efficacy and more significant side effects when compared to propranolol.15,16

Laser and Surgical Therapy

For many years, pulse dye laser (PDL) has been used as either a mono- or adjuvant therapy. It has proven useful in reducing residual telangiectasia and redness in older children. Some providers consider it more useful early on, noting that early treatment with PDL with or without adjuvant systemic therapy may lead to a more rapid response and decrease the risk of more serious sequelae.17 It may diminish pain and increase healing time in ulcerated lesions in the perineum.2 Hemangiomas may ulcerate at lower fluences so it is important to start treatment at lower energy levels. The Nd-Yag laser has been used successfully to treat thicker, non-responsive lesions. Notably, there is a higher risk of scar with this laser.2 Fractional CO2 laser has been used to treat residual textural changes and scars. Ma et al reported successful treatment of deep hemangiomas with fractionated CO2 laser used in combination with topical timolol.18
Excisional surgery is generally considered if there are residual skin changes after involution. However in certain cases earlier surgery is reasonable. Examples of this include for IH, which are very exophytic or pedunculated, where a scar is highly likely to be present even after involution or where medical therapies have failed to have expected effects. Emerging evidence suggests that most involution is completed by 3 to 4 years of age.19 Hence it is always appropriate to re-evaluate around that age to consider what treatment options are needed if significant residua are still present.

Disclosure

Dr. Frieden is a consultant for Pierre Fabre Dermatology.

References

  1. Kanada KN, Merin MR, Munden A, Friedlander SF. A prospective study of cutaneous findings in newborns in the United States: correlation with race, ethnicity, and gestational status using updated classification and nomenclature. J Pediatr. 2012;161(2):240-245. doi:10.1016/j.jpeds.2012.02.052.
  2. Chen TS, Eichenfield LF, Friedlander SF. Infantile hemangiomas: an update on pathogenesis and therapy. Pediatrics. 2013;131(1):99-108. doi:10.1542/ peds.2012-1128.
  3. Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. 2007;150(3):291-294. doi:10.1016/j.jpeds.2006.12.003.
  4. Luu M, Frieden IJ. Haemangioma: clinical course, complications and management. Br J Dermatol. 2013;169(1):20-30. doi:10.1111/bjd.12436.
  5. Tollefson MM, Frieden IJ. Early growth of infantile hemangiomas: what parents’ photographs tell us. Pediatrics. 2012;130(2):e314-e320. doi:10.1542/ peds.2011-3683.
  6. Marqueling AL, Oza V, Frieden IJ, Puttgen KB. Propranolol and infantile hemangiomas four years later: a systematic review. Pediatr Dermatol. 30(2):182-191. doi:10.1111/pde.12089.
  7. Couto JA, Greene AK. Management of problematic infantile hemangioma using intralesional triamcinolone: Efficacy and safety in 100 infants. J Plast Reconstr Aesthet Surg. 2014;67(11):1469-1474. doi:10.1016/j.bjps.2014.07.009.
  8. Qiu Y, Ma G, Yang J, et al. Imiquimod 5% cream versus timolol 0.5% ophthalmic solution for treating superficial proliferating infantile haemangiomas: a retrospective study. Clin Exp Dermatol. 2013;38(8):845-850. doi:10.1111/ ced.12150.
  9. Martin K, Blei F, Bleib F, et al. Propranolol treatment of infantile hemangiomas: anticipatory guidance for parents and caretakers. Pediatr Dermatol. 30(1):155-159. doi:10.1111/pde.12022.
  10. Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics. 2013;131(1):128-140. doi:10.1542/peds.2012-1691.
  11. Léauté-Labrèze C, Hoeger P, Mazereeuw-Hautier J, et al. A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma. N Engl J Med. 2015;372(8):735-746. doi:10.1056/NEJMoa1404710.
  12. Ahogo CK, Ezzedine K, Prey S, et al. Factors associated with the relapse of infantile haemangiomas in children treated with oral propranolol. Br J Dermatol. 2013;169(6):1252-1256. doi:10.1111/bjd.12432.
  13. Langley A, Pope E. Propranolol and central nervous system function: potential implications for paediatric patients with infantile haemangiomas. Br J Dermatol. 2015;172(1):13-23. doi:10.1111/bjd.13379.
  14. Pope E, Chakkittakandiyil A, Lara-Corrales I, Maki E, Weinstein M. Expanding the therapeutic repertoire of infantile haemangiomas: cohort-blinded study of oral nadolol compared with propranolol. Br J Dermatol. 2013;168(1):222-224 doi:10.1111/j.1365-2133.2012.11131.x.
  15. Bauman NM, McCarter RJ, Guzzetta PC, et al. Propranolol vs prednisolone for symptomatic proliferating infantile hemangiomas: a randomized clinical trial. JAMA Otolaryngol Head Neck Surg. 2014;140(4):323-330. doi:10.1001/ jamaoto.2013.6723.
  16. Bennett ML, Fleischer AB, Chamlin SL, Frieden IJ. Oral corticosteroid use is effective for cutaneous hemangiomas: an evidence-based evaluation. Arch Dermatol. 2001;137(9):1208-1213. http://www.ncbi.nlm.nih.gov/ pubmed/11559219. Accessed February 9, 2015.
  17. Admani S, Krakowski AC, Nelson JS, Eichenfield LF, Friedlander SF. Beneficial effects of early pulsed dye laser therapy in individuals with infantile hemangiomas. Dermatol Surg. 2012;38(10):1732-1738. doi:10.1111/j.1524- 4725.2012.02487.x.
  18. Ma G, Wu P, Lin X, et al. Fractional carbon dioxide laser-assisted drug delivery of topical timolol solution for the treatment of deep infantile hemangioma: a pilot study. Pediatr Dermatol. 31(3):286-291. doi:10.1111/pde.12299.
  19. Couto RA, Maclellan RA, Zurakowski D, Greene AK. Infantile hemangioma: clinical assessment of the involuting phase and implications for management. Plast Reconstr Surg. 2012;130(3):619-624. doi:10.1097/ PRS.0b013e31825dc129.

AUTHOR CORRESPONDENCE

Shanna Spring MDshanna.spring@utoronto.ca
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