Infantile Hemangioma Treatment & Management

Updated: Oct 02, 2017
  • Author: Richard J Antaya, MD; Chief Editor: William D James, MD  more...
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Treatment

Medical Care

The majority of infantile hemangiomas do not require any medical or surgical intervention. [8] Historically, medical care of clinically significant hemangiomas had been limited to a few medications, including glucocorticosteroids (topical, intralesional, and oral), interferon alfa, and, rarely, vincristine and topical imiquimod. [63] Beta-blockers, most specifically propranolol, [64] have been shown to induce involution of infantile hemangiomas and are now considered first-line treatment for problematic infantile hemangiomas. [65, 66, 67, 68] There is an FDA-approved formulation of propranolol solution indicated for the treatment of infantile hemangiomas for infants aged 5 weeks to 5 months. [69]

An expert panel has developed provisional recommendations for the use of propranolol, including in patients with PHACE syndrome (posterior fossa abnormalities, hemangioma, arterial lesions, cardiac abnormalities/aortic coarctation, and eye abnormalities). [10, 11] PHACE syndrome is associated with a higher risk of neurologic and cognitive impairment.

The provisional recommendations cover the following [10, 11] :

  • When to treat complicated infantile hemangiomas
  • Contraindications and pretreatment evaluation protocols
  • Formulation, target dose, and frequency of dosing
  • Initiation in infants
  • Cardiovascular monitoring
  • Ongoing monitoring
  • Prevention of hypoglycemia

The individual therapies are discussed in detail under Medication.

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Surgical Care

Laser surgery

Laser surgery is beneficial in treating both proliferating and residual vessels from hemangiomas. The flashlamp-pumped pulsed-dye laser has become the most widely used laser for selective ablation of vascular tissue in childhood.

Pulsed-dye laser surgery is effective for treating ulcerated hemangiomas and thin superficial hemangiomas, especially those on areas likely to result in significant functional or psychological impact (eg, fingers, eyes, lips, nasal tip, ears, face). [12, 13] Many ulcerated hemangiomas respond with decreased pain (sometimes as early as a few days after the initial treatment), rapid reepithelialization, and hastened involution.

Treatments generally are performed every 2-4 weeks until complete healing results. Occasionally, particularly with deep or combined superficial and deep lesions, ulceration may worsen with pulsed-dye laser treatment. [70]

The risk of scarring or residual skin changes associated with pulsed-dye laser surgery of hemangiomas may be greater than without early laser treatment or with the treatment of capillary malformations (port wine stains), but the benefits of early involution should be weighed against the risks of a passive approach or alternative therapies. [52, 71]

Other lasers that appear to be efficacious in treating hemangiomas include the pulsed Nd:YAG, frequency-doubled Nd:YAG, and KTP lasers. A systematic review of laser treatment of infantile hemangiomas found most data on pulsed-dye lasers (PDLs). Some studies suggest that longer-pulse PDL (10-20 millisecond pulse width) therapy may offer a therapeutic advantage, but not enough data are available to make recommendations on any parameter or laser. [72] Carbon dioxide lasers are occasionally used for airway hemangiomas. [73] Each of these lasers has specific benefits and limitations regarding depth of penetration, absorption of skin chromophores, and caliber of the vessel treated. Complications also vary depending on the laser, settings, and site treated. [74]

The use of nonablative fractional photothermolysis (nFP) for the treatment of the anetodermic fibrofatty residua in involuted infantile hemangiomas may be an alternative to surgical excision. [75]

See Laser Treatment of Acquired and Congenital Vascular Lesions for a detailed discussion.

Surgical excision

Surgical excision of involuted hemangiomas is not uncommon because of the cutaneous defects resulting from them. [14] Atrophic and hypertrophic scars, as well as anetodermic and tumoral fibrofatty skin, may result in significant cosmetic or functional impairment. The benefits of excision during late involution include a reduced risk of hemorrhage and a potentially smaller lesion because of the natural course. In addition, because involuted hemangiomas are composed primarily of fibrofatty tissue, complete removal of all tissue is unnecessary, while removing too much tissue could detract from proper contours.

Surgical excision of proliferating hemangiomas is potentially hazardous because of the risk of hemorrhage and damage to vital structures associated with them (ie, head, neck); therefore, only specially trained surgeons should perform this procedure. Certain benefits to early excision include saving a life or preserving vision and decreasing the negative psychosocial effects associated with a cosmetically disfiguring lesion during early childhood. Other benefits of early excision include the use of naturally expanded skin to aid in primary closure and the ability to use a relatively avascular tissue plane surrounding actively growing hemangiomas. New advancements in surgical instruments that cauterize while cutting lessen the risk of hemorrhage. Treatment with propranolol has resulted in a significant decrease in the need for surgery in at least one center. [76]

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Consultations

An ophthalmologist or a pediatric ophthalmologist should evaluate children with periorbital hemangiomas, particularly with involvement of the upper eyelid. Refraction with retinoscopy is performed to evaluate for visual disturbances, particularly astigmatism, and to prevent visual deprivation amblyopia. Also see Capillary Hemangioma in the Medscape Reference Ophthalmology section.

Infants with rapidly growing hemangiomas that are impinging on vital structures of the head and neck, particularly the airway or auditory canals, should be referred to an otolaryngologist or a pediatric otolaryngologist for evaluation and treatment. Infants with large V3 dermatomal hemangiomas (beard area hemangiomas) have a higher incidence of upper airway hemangiomas, and early consultation for mild signs or symptoms (noisy breathing or stridor) may prevent possible future complications.

Consultation with a plastic surgeon is indicated for symptomatic involuting or proliferating lesions that are unresponsive to medical therapy and for which surgical excision is being contemplated.

The presence of an infantile hemangioma over the midline lumbar back may be a cutaneous sign of an underlying occult spinal dysraphism, such as a tethered cord. MRI or ultrasonography if the infant is younger than 5 months is indicated for midline hemangiomas, especially if any other signs of spinal dysraphism (eg, deviated gluteal cleft, atypical sacral dimple, tuft of hair, tail) are present. MRI is the more sensitive study, even in infancy, and should be considered when clinical suspicion is high. Consultation with a pediatric neurosurgeon should be sought for any questionable or worrisome lesions.

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