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Hemangiomas
are the most common tumor of infancy, developing in 10% of
children by 2 months of age. Although most hemangiomas resolve
without intervention, all dermatology practitioners who treat
pediatric patients can expect to be called upon to assist
primary care providers and parents with the management of
these lesions. Therefore, it is imperative that dermatologists
diagnose these lesions early in the course, recognize hemangiomas
at risk for complications, and treat complicated lesions appropriately.
Our focus is on hemangiomas with ulcerations, the most frequent
complication associated with these tumors. These ulcerations,
which may persist for months when untreated, are associated
with pain, bleeding, infection, disfigurement, and scarring,
so immediate consultation and treatment may be required.
Over the last 10 years, investigators have taught us to recognize
lesions at high risk for ulceration based on location, anatomic
depth, size, pattern, and growth phase. Most ulcerated hemangiomas
are located in periorificial sites, particularly the diaper
area and mouth. Lesions in areas of trauma such as intertriginous
sites are also at risk. Hemangiomas with a prominent superficial
component are at greater risk of ulceration than those that
are primarily deep dermal or subcutaneous.
Although ulcerated lesions can be any size, they tend to be
relatively large, and often develop in a segmental pattern
(recognizable patterns, eg, dermatomal, lines of Blaschko,
petaloid), while focal (single round to oval and nonpatterned)
and multifocal lesions are at lowest risk. Finally, most ulcerations
develop in the proliferative phase, particularly during the
first 2-6 months of life, and only rarely develop after 10
months of age.
Although effective management of ulcerated hemangiomas may
include multiple concurrent modalities, early conservative
treatment is often effective. Topical antibiotics (eg, mupirocin,
retapamulin), barrier pastes (eg, zinc oxide 20%), and gentle
cleansing and debridement with tepid tap water may result
in clearance of erosions, crusts, and superficial ulcerations
in stable hemangiomas. Bio-occlusive dressings, absorbant
nonstick dressings, alginate dressings, and petrolatum-impregnated
gauze may result in immediate improvement in pain as well
as potentiate debridement and healing.
Ulcerated rapidly-growing hemangiomas may require systemic
therapy (eg, oral corticosteroids 2-3 mg/kg/day) to shut off
the proliferative process before healing of the ulcer can
be achieved. Rapid healing of ulcerations recalcitrant to
conservative measures may respond quickly (within 2-4 weeks)
to pulsed dye laser with minimal risk to the infant. Concurrent
treatment with experimental topical therapies including imiquimod,
recombinant human platelet derived growth factor, steroids,
and new antiangiogenic agents may also trigger re-epithelialization.
Successful management of ulcerated hemangiomas requires immediate
attention to pain, which is often neglected in newborns and
infants. Consistent use of oral acetaminophen or acetaminophen
with codeine, as well as judicious application of topical
anesthetics, may also be necessary.
The clinician must also be prepared to counsel families regarding
the anticipated course of ulcerated hemangiomas and the safety
and efficacy of treatment strategies to gain their confidence
and ensure compliance. Ongoing communication with families
by phone and online digital imaging can be used to assess
progress. Communication and collaboration with the primary
care provider is also critical.
Finally, increased understanding of the biochemical and molecular
aspects of angiogenesis and wound healing will undoubtedly
lead to new treatment options. Although there are no rigorous
evidence-based studies and no FDA-approved treatments, current
efforts by the Hemangioma Investigators Group and other investigators
will hopefully make these new treatments safe and consistently
effective. |
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