Day: January 9, 2012

When Is More Treatment Needed for Infantile Hemangiomas?

Patient Presentation
A 9-month-old male came to clinic with a 2 day history of intermittent bleeding from one of his hemangiomas on his left arm. The bleeding was mainly of serous fluid with a small amount of blood. It was easily controlled with pressure and a bandage changed 2-3 times per day contained the fluid. The patient did not appear in pain and did not have redness around the lesion or fever. The patient was otherwise well. His mother was concerned because she had been told that if bleeding kept happening then he might need some treatment. The past medical history showed a healthy male infant who had his first hemangioma on his left lateral back appear around 6 weeks of age. Three others than appeared on his left arm, left flank and right anterior chest. All had increased in size but had been stable per his mother for a couple of months.

The pertinent physical exam showed a smiling infant with growth parameters in the 10-50%. His cardiac and abdominal examinations were negative. His skin examination showed one 0.5 cm cafe-au-lait spot on his right posterior calf. The left lateral back had a 5 mm x 2 mm raised red lesion that was circular. The left flank had a 10 mm x 3 mm raised red lesion that was circular. The right anterior chest had a 12 mm x 3 mm raised red lesion that was mainly oval but slightly more irregular. All had distinct borders and consistent coloration. The left arm was 22 mm x 5 mm raised red lesion that was circular. About 10 o’clock to the center of the lesion was a “crack” with a minimal amount of serous fluid. A thin wet scab was present. No pain or tenderness was elicited and there was no red streaking from the lesion. There was full range of motion in the arm. Documentation from previous visits showed the lesions to be about the same size previously. The diagnosis of a probably traumatized hemangioma was made. The mother was told to continue to monitor it and try to minimize repeated trauma if possible. She was also told how to control bleeding if necessary. The physician reiterated the natural history of the lesions and didn’t believe further treatment was necessary at this time unless the bleeding got worse or would not resolve.

Discussion
Infantile hemangiomas (IH) are the most common soft tissue tumors in infants. They are usually considered birthmarks but are dynamic lesions. They usually begin in the first few weeks of life and rapidly grow in the first 3-5 months of life. By 5 months, most lesions will have achieved 80% of their final size. Almost all IH have cessation of growth after 9 month of age. Images of IH can be seen in the To Learn More section below.

Learning Point
Often no treatment is necessary for IH other than expectant monitoring. Additional treatment may be necessary depending on the patient’s age, lesion type, location, size and complication being considered.

The results of a prospective cohort of 1058 children in 7 pediatric dermatology clinics found that overall 24% of patients had complications and 38% needed treatment. Hemangiomas are more likely to have complications and receive treatment if they are:

  • Type: segmental (55.5%) or intermediate (24.9%); localized (9.6%) or multifocal (9.1%) were less likely
  • Location: perineum (47.9%), face (43.0%) and head and neck (31.1%). Those on the extremity (20.6%) and the trunk (11.5%) are less likely
  • Size: Large are more likely than small

Hemangioma complications include:

  • Ulceration – the most common complication. A white discoloration on the lesion may be involution or ulceration. Ulceration is painful and usually heals with scaring.
  • Bleeding – significant hemorrahage is rare
  • Cardiac failure
  • Infection – cellulitis, abscess
  • Obstruction of vital organs with associated morbidity- eye, airway
  • Element of syndrome or other process
    • Hypothyroidism
    • Diffuse neonatal hemangiomatosis
    • Kasabach-Merritt phenomenon
    • PHACE syndrome
    • PELVIS or SACRAL syndrome
    • Occult spinal dysraphism
  • Scaring/disfigurement
  • Psychosocial problems for patient and family

Treatment includes antibiotics, dressings, pulsed-dye laser or other type of laser surgery, surgical excision, propanolol, corticosteroids, and recombinant growth factors.
Consultations with dermatology, otolaryngology, ophthalmology, and plastic surgery may be necessary.

Questions for Further Discussion
1. What birthmarks are potential signs of an underlying medical problem?
2. What treatment options can be considered for recurrent bleeding in infantile hemangioma?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Benign Tumor and Birthmark.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, Lucky AW, Mancini AJ, Metry DW, Newell B, Nopper AJ, Frieden IJ. Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment. Pediatrics. 2006 Sep;118(3):882-7.

Chang LC, Haggstrom AN, Drolet BA, Baselga E, Chamlin SL, Garzon MC, Horii KA, Lucky AW, Mancini AJ, Metry DW, Nopper AJ, Frieden IJ; Hemangioma Investigator Group. Growth characteristics of infantile hemangiomas: implications for management. Pediatrics. 2008 Aug;122(2):360-7.

Antaya RJ, Dirk M, Elston DM. Infantile Hemangioma. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/1083849-treatment (rev. 7/27/2011, cited 10/24/11).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital