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Infantile hemangioma treatment
Given the wide spectrum of disease, unpredictable growth and the natural tendency for involution, the greatest challenge in caring for infants with hemangiomas is determining which infants need aggressive treatment or are at highest risk for complications. The decision to treat should be tailored to each specific hemangioma, taking into account the patient's age, location of hemangioma, size of hemangioma, rate of growth of hemangioma and potential for complications. Each infant's hemangioma will behave differently and all need to be addressed with an individualized manner. Some hemangiomas will grow rapidly and require aggressive therapy, while others may not grow at all. In general, larger hemangiomas located on the face are more likely to require treatment.
Treatment options for infantile hemangiomas
Joseph Kerschner, MD, is an otolaryngologist who uses a variety of birthmark treatments. Even though most hemangiomas will not require an oral medication or surgery, we believe all hemangiomas should be monitored closely, especially during infancy. Hemangiomas undergo the most rapid period of growth during the first months of life. Hemangiomas should be monitored during this period for rapid growth and complications.
Oral systemic corticosteroids have become a mainstay in the treatment of hemangiomas, yet their mechanism of action is not well understood. The oral steroids are used to control or stop the growth of the hemangioma. They are only used during the growth period, and in most cases do not usually shrink the hemangioma but control its growth. Despite a list of potential side effects, including irritability, gastrointestinal upset, immunosuppression, hypertension, and growth retardation, most treated infants do well. By closely monitoring the patient, parents and physicians can usually minimize the chances of any ill effects from this treatment. The duration of treatment ranges from a few weeks to many months, depending on the child's age, the indications for treatment and the growth characteristics of the hemangioma.
Corticosteroids can also be injected directly into the hemangioma and are effective for small, localized, cutaneous hemangiomas. Topical steroids have also recently been found to be effective in controlling the growth of small superficial hemangiomas, particularly on the eyelid and around the mouth.
Surgical excision is used most frequently to reconstruct scars or to remove fibrofatty tissue, but early excision is a reasonable option in selected cases where a residual abnormality is virtually inevitable or where the hemangioma threatens life or bodily function and drug therapy is not effective or well tolerated. In cases without medical complications, where uncertainty exists about outcome, the pros and cons of a surgical approach must be weighed carefully since the scar left from an excision may be worse than the results from spontaneous regression. Generally reevaluation is recommended at about age 4 to assess how much residual hemangioma is present and to consider surgery for hemangiomas that are causing scarring or regress very slowly.
Laser therapy has also been used to treat hemangioma. Because of its limited depth of penetration, the flash-lamp pulsed dye laser works well for superficial hemangiomas but has no impact on deeper or thicker hemangiomas. It is most often used to improve the telangiectasia (broken blood vessels) after regression, and is effective in treating ulcerated hemangiomas resulting in decreased pain and more prompt healing.
Continuous-wave lasers such as the Argon, Neodymium:yttrium-aluminium-garnet and potassium titanyl phosphate have also been used but are more operator dependent and have a greater risk of scarring.
Subcutaneous injection of a recombinant interferon-alpha has been used successfully in treating life-threatening hemagiomas that have failed to respond to oral corticosteroid therapy. Interferon-alpha has been shown to decrease new blood vessel growth (angiogenesis) and therefore was theorized to be effective for hemagiomas. Common side effects include irritability, neutropenia, and liver enzyme abnormalities. A particularly worrisome neurologic side effect, spastic diplegia, has recently been reported in as many as 20 percent of patients. Therefore, interferon-alpha should be reserved for only the most serious, life-threatening hemangiomas that have failed high-dose corticosteroid therapy and, when administered, neurologic status should be monitored closely.
Rarely, embolization has been used in the treatment of cutaneous hemangiomas that have failed medical therapy.
Vincristine is a medication that is used to treat a variety of tumors. Recently, it has been used successfully to treat hemangiomas that threaten to affect a vital function. Vincristine may be used if there is a concern that the hemangioma may cause loss of sight or compromise the infant's airway. This medication is given as an injection into a central venous line on a weekly basis.
Propranolol is a medication that has been used for many years to treat high blood pressure. Recently it was recognized that Propranolol may work for the treatment of hemangiomas. It must be used with caution because it can cause a drop in blood sugar if the infant does not eat regularly. It also may cause a drop in blood pressure or heart rate. Close observation is necessary. This medication is given by mouth two to three times a day.
Regranex gel is a topical medication that may be used on ulcerated hemangiomas. Regranex contains a platelet-derived growth factor and is used on ulcerated hemangioma to help them heal faster than wound care alone. Ulcerated hemangiomas in most infants are very painful and take several weeks to heal. Regranex is used once daily to help speed the healing process. Regranex is costly and many insurance companies require a pre-authorization before the prescription can be filled. Regranex is FDA approved to be used on adult diabetic foot ulcers.
The FDA has not approved the use of any medication for the treatment of infantile hemangiomas. There are research studies being done at Children's Wisconsin to find the safest and most beneficial treatments for hemangiomas.
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