Capillary Hemangioma Treatment & Management

The indications for treatment can be divided into systemic, ophthalmic, and dermatologic reasons. Systemic reasons for intervention include congestive heart failure, thrombocytopenia, hemolytic anemia, and nasopharyngeal obstruction. Ophthalmic indications for intervention include occlusion of the visual axis, optic nerve compression, severe proptosis, and anisometropia.^{[4, 5]} Dermatologic indications for intervention include maceration and erosion of the epidermis, infection, and cosmetic disfigurement.

• The first-line treatment of capillary hemangiomas is simple observation. Since most of these lesions regress on their own, there is no need to intervene unless one of the above criteria is met.^[6]
• Corticosteroids, in various formulations, also have been used in the treatment of capillary hemangiomas.^{[7, 8, 9, 10, 11, 12, 13]}

  • Topical steroid formulations, such as clobetasol propionate cream, can be applied topically to the lesion. The response to these treatments, even with the strongest corticosteroid formulations, is slower than other methods because several weeks are required to obtain a response.
  • Complications include dermal atrophy, pigmentary changes in the skin, and dermatitis, as well as less common ophthalmic complications, such as elevated intraocular pressure and cataract formation. Systemic absorption also can occur.
  • Overall, this modality is not appropriate for vision-threatening lesions.
• Injectable steroid formulations also are used in the treatment of these lesions.

  • Endothelial cell sensitization to catecholamines is the mechanism by which intralesional corticosteroids exert their effects. Although there may be a period of temporary enlargement, blanching usually is noted within 2-3 days and involution is seen by 2-4 weeks. Their effectiveness is most pronounced 2 weeks after injection but can be seen up to 2 months later. The overall success rate for this intervention is 75%.
  • Risks of injection include lid necrosis, depigmentation, and fat necrosis. The most disconcerting adverse effect concerns reports of central retinal artery occlusion following the intralesional injection of corticosteroids. Although the precise pathogenesis is uncertain, some suggest it may be related to anomalous vessels. A technically slower injection of corticosteroid or a smaller volume of solution may lessen the risk.^{[14, 15, 16]}
  • Steroid injections can be repeated, but, ideally, they should be separated in time by 2-3 months to allow for maximum benefit to be seen. Adrenal suppression after cutaneous steroid injections has been reported.
• Systemic corticosteroids are used for amblyogenic life-threatening lesions.

  • An excellent response rate can be expected in 30% of patients, a questionable response in 40%, and no response in 30% when systemic corticosteroids are used under close observation. The response may be quite dramatic within the first 2 weeks, and the effect may last from 1-4 months. Doses of 2-3 mg/kg may be necessary for up to several months.
  • Complications of systemic therapy with corticosteroids include Cushingoid changes, personality changes, gastrointestinal irritation, oral candidiasis, delayed growth, diabetes, hypertension, and rebound growth of hemangiomas on cessation.
• Interferon alfa-2a has emerged as a new modality to combat the life-threatening and vision-threatening hemangiomas of infancy that are resistant to steroid treatment.^[17] While it has potent effects on these lesions, it is commonly associated with adverse effects of varying severity.

  • Interferon alfa-2a exerts its effect by preventing endothelial cell migration in capillary hemangiomas. Authors have shown significant tumor regression after treatment with interferon.
  • Unfortunately, adverse effects from treatment may have somewhat dampened the initial excitement with this treatment. Adverse effects include fever, chills, arthralgias, and retinal vasculopathy. Of more significance, the incidence of spastic diplegia has been as high as 20% in some reports, leading some to reevaluate the benefits of its use. The long-term effects of interferon on the developing brain are unknown.
• Systemic propranolol has been added to the scope of treatment modalities available to patients with hemangiomas.

  • The literature surrounding this management option largely consists of anecdotal case reports, but an article by Al Dhaybi et al describes great success with oral propranolol, discontinued in only 1 of 18 patients due to side effects.^[18] A reduction occurred in both radiographic volume and amblyogenic astigmatism.
  • A study by Missoi et al showed a 33% reduction in astigmatism and a 39% reduction in surface area in 17 children who were treated over a median duration of 6.8 months, suggesting that early intervention with propranolol is also effective for the treatment and prevention of visual acuity loss associated with periocular infantile hemangiomas.^[19]
  • Propranolol has been suggested to be effective in reducing the size of juvenile hemangiomas, and, for patients who meet criteria for treatment of these lesions, it is worth consideration. The treatment does have potential complications, particularly cardiac, and patients need to be monitored closely.^[20] It is highly recommended that the medication is administered and monitored for dose titration and systemic side effects by a pediatrician or pediatric cardiologist.

• Laser surgery has been attempted to ameliorate capillary hemangiomas but is still controversial. The hemostatic effects of the carbon dioxide laser have been used with success to surgically remove these lesions. Other lasers used include the argon laser and the Nd:YAG laser. The pulsed dye laser is only effective for very superficial lesions; its mechanism of action is too slow for sight-threatening hemangiomas. Overall, variable results have been seen with various laser modalities, and the risks of scarring and ulceration often deter its use.
• Incisional surgical techniques also have had variable success. Surgical ligation of the hemangiomas produces equivocal results. Vascular embolization of the lesions should be used for large extraorbital hemangiomas only. Primary excision also has been advocated for infantile hemangiomas. Early surgical intervention can be considered as a primary treatment option in selected, isolated capillary hemangiomas without a significant cutaneous component. Surgery can provide definitive early treatment and prevent astigmatism and occlusion-related amblyopia.^{[21, 22]}

• Consultations with a pediatrician may be necessary to monitor for the systemic adverse effects if prednisone is used or if there is suspicion of systemic involvement.
• Pediatric dermatologists may have particular expertise in the various treatment options available.