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Hemangioma, Capillary: Treatment & Medication
Updated: Jun 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
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.
Surgical Care
- 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.18,19
Consultations
- 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.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Deltasone)
Decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation, and decreasing capillary vasoconstriction.
Adult
Pediatric
2-3 mg/kg/d for up to several mo may be necessary to cause regression of lesions; close monitoring at these high doses is essential
Coadministration with anticholinesterase agents may prolong their effects; corticosteroid-induced potassium loss may potentiate digoxin toxicity and cause severe hypokalemia if used with potassium-depleting diuretics; anticoagulant action may be prolonged with concurrent steroid administration; caution must be taken in patients with diabetes mellitus, osteoporosis, hypertension, or impaired liver function
Documented hypersensitivity; fungal, viral, tubercular skin infections; peptic ulcer disease; hepatic dysfunction; connective tissue infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
With sudden cessation of long-term steroid use, adrenal insufficiency may occur; steroid psychoses, immunosuppression, impaired wound healing, osteoporosis, peptic ulcer disease, and growth suppression are also adverse effects of corticosteroid usage
Clobetasol propionate 0.05% (Temovate)
Decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation. Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Adult
Pediatric
Apply to affected area qd/bid; not to exceed 50 g/wk
None reported
Documented hypersensitivity; cutaneous fungal or tubercular infections, or viral infections (eg, varicella, herpes simplex)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Significant systemic absorption may occur if used chronically or under occlusive dressings; application to the eyelid skin must be monitored carefully because of the thin skin and higher than normal systemic absorption
Betamethasone (Celestone)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
Pediatric
1 cc of a 6 mg/cc solution combined with 1 cc of a 40 mg/cc solution of triamcinolone
Effects decrease with coadministration of barbiturates, phenytoin and rifampin
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Local adverse effects include fat atrophy, skin hyperpigmentation, and central retinal artery occlusion; systemic absorption increases risk of multiple complications, including severe infections, adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, and growth suppression
Triamcinolone (Kenalog)
Treats inflammatory dermatosis that is responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
Pediatric
1 cc of a 40 mg/cc solution combined with 1 cc of a 6 mg/cc solution of betamethasone (see separate section)
Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Local adverse effects include fat atrophy, skin hyperpigmentation, and central retinal artery occlusion; systemic absorption increases risk of multiple complications, including severe infections, adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, and growth suppression
More on Hemangioma, Capillary |
| Overview: Hemangioma, Capillary |
| Differential Diagnoses & Workup: Hemangioma, Capillary |
Treatment & Medication: Hemangioma, Capillary |
| Follow-up: Hemangioma, Capillary |
| References |
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References
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Rosca TI, Pop MI, Curca M, et al. Vascular tumors in the orbit--capillary and cavernous hemangiomas. Ann Diagn Pathol. Feb 2006;10(1):13-19. [Medline].
Kavanagh EC, Heran MK, Peleg A, et al. Imaging of the natural history of an orbital capillary hemangioma. Orbit. Mar 2006;25(1):69-72. [Medline].
Weiss AH, Kelly JP. Reappraisal of astigmatism induced by periocular capillary hemangioma and treatment with intralesional corticosteroid injection. Ophthalmology. Feb 2008;115(2):390-397.e1. [Medline].
Goggin M. Astigmatism and periocular hemangioma. Ophthalmology. Oct 2008;115(10):1854-5; author reply 1855. [Medline].
Wittenberg L, Ma P. Treatment of a von Hippel-Lindau retinal capillary hemangioma with photodynamic therapy. Can J Ophthalmol. Oct 2008;43(5):605-6. [Medline].
Assaf A, Nasr A, Johnson T. Corticosteroids in the management of adnexal hemangiomas in infancy and childhood. Ann Ophthalmol. Jan 1992;24(1):12-8. [Medline].
Boon LM, MacDonald DM, Mulliken JB. Complications of systemic corticosteroid therapy for problematic hemangioma. Plast Reconstr Surg. Nov 1999;104(6):1616-23. [Medline].
Cruz OA, Zarnegar SR, Myers SE. Treatment of periocular capillary hemangioma with topical clobetasol propionate. Ophthalmology. Dec 1995;102(12):2012-5. [Medline].
Elsas FJ, Lewis AR. Topical treatment of periocular capillary hemangioma. J Pediatr Ophthalmol Strabismus. May-Jun 1994;31(3):153-6. [Medline].
Kushner BJ. Intralesional corticosteroid injection for infantile adnexal hemangioma. Am J Ophthalmol. Apr 1982;93(4):496-506. [Medline].
O'Keefe M, Lanigan B, Byrne SA. Capillary haemangioma of the eyelids and orbit: a clinical review of the safety and efficacy of intralesional steroid. Acta Ophthalmol Scand. Jun 2003;81(3):294-8. [Medline].
Friling R, Axer-Siegel R, Ben-Amitai D, et al. Intralesional and sub-Tenon's infusion of corticosteroids for treatment of refractory periorbital and orbital capillary haemangioma. Eye. Nov 7 2008;[Medline].
Shorr N, Seiff SR. Central retinal artery occlusion associated with periocular corticosteroid injection for juvenile hemangioma. Ophthalmic Surg. Apr 1986;17(4):229-31. [Medline].
Weiss AH. Adrenal suppression after corticosteroid injection of periocular hemangiomas. Am J Ophthalmol. May 15 1989;107(5):518-22. [Medline].
Deboer MD, Boston BA. Failure-to-thrive in an infant following injection of capillary hemangioma with triamcinolone acetonide. Clin Pediatr (Phila). Apr 2008;47(3):296-9. [Medline].
Barlow CF, Priebe CJ, Mulliken JB, et al. Spastic diplegia as a complication of interferon Alfa-2a treatment of hemangiomas of infancy. J Pediatr. Mar 1998;132(3 Pt 1):527-30. [Medline].
Deans RM, Harris GJ, Kivlin JD. Surgical dissection of capillary hemangiomas. An alternative to intralesional corticosteroids. Arch Ophthalmol. Dec 1992;110(12):1743-7. [Medline].
Slaughter K, Sullivan T, Boulton J, et al. Early surgical intervention as definitive treatment for ocular adnexal capillary haemangioma. Clin Experiment Ophthalmol. Oct 2003;31(5):418-23. [Medline].
Further Reading
Keywords
capillary hemangioma, capillary hemangiomas, orbital tumor, benign endothelial cell neoplasm, vascular malformation, vascular anomaly
Treatment & Medication: Hemangioma, Capillary