Link to article (book chapter): http://viewer.zmags.com/publication/0777a968#/0777a968/93
Article Review:
Doctors Pristine Lee (Pediatric Dermatologist, Kaiser San Rafael) and Ilona Frieden from the University of California, San Francisco, published a recent report at the American Academy of Dermatology conference in 2011, reviewing the current literature on the use of beta-blockers for the treatment of Infantile Hemangiomas (IH). The decision to intervene and treat an IH is predicated on the risk of long-term scarring or disfigurement, functional compromise of adjacent organs and life threatening complications from the IH. Factors involving anatomic location, size, depth of the lesion, and the child’s age are all taken into consideration in determining treatments.
In 2008, Propranolol was discovered as a safe and efficacious treatment for Infantile Hemangiomas. Since then, over 75 publications have demonstrated marked improvement and rapid involution of these lesions with both systemic and topical propranolol therapy. A recent study by Holmes et al showed that over half of patients with IH had significant regression of their lesion after two weeks of therapy. Historically, systemic corticosteroids have been used to treat some hemangiomas. And, while steroids suppress the growth of hemangiomas, they are less successful than propranolol in promoting involution of these lesions.
Propranolol, either alone or in combination with steroids has been shown to be effective for hemangiomas of the airway and liver. Propranolol has reduced the size of these lesions remarkably better than systemic steroids and chemotherapeutic agents. Some patients with IH have had little or no response to propranolol, although these represent a minority of patients. Rebound growth of IH has occurred in a subset of patients once the propranolol has been tapered or stopped. These patients required a prolonged course of propranolol following this rebound phenomenon.The safety profile of propranolol in newborns and infants is well established, and is considered safer than systemic steroids. At appropriate doses it is well tolerated, however some rare complications include bradycardia, bronchospasm, hypoglycemia and labile blood pressures.
While complex infantile hemangiomas requiring systemic propranolol will be managed in conjunction with a pediatric dermatologist, superficial infantile hemangiomas can be managed by the general pediatrician using topical propranolol, Timolol. This is an opththalmic preparation of propranolol and has been used for glaucoma. Studies and case reports have shown that twice-daily use over 1 to 3 months oTimolol has resulted in marked involution of IH.
** Permanente Medicine Today will be sponsoring a videoconference on Pediatric Hemangiomas on August 10th, 2012. **
Hemangioma Work-up
Where
|
What
|
Evaluation
|
Facial, large segmental
|
PHACE syndrome
|
Echocardiogram
Ophthalmology MRI/MRA of the brain & neck |
Periorbital and retrobulbar
|
Ocular axis occlusion, astigmatism, amblyopia, tear-duct occlusion
|
Ophthalmology
|
Nasal tip, ear, large facial
|
Permanent scarring, disfigurement
| |
Segmental "beard area," central neck
|
Airway hemangioma
|
Otolaryngology
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Perioral
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Ulceration, disfigurement, feeding difficulties
| |
Segmental overlying lumbosacral spine
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Tethered spinal cord, genitourinary anomalies
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MRI of lumbosacral spine, consider renal ultrasound
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Perineal, axilla, neck, perioral
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Ulceration
| |
Multiple hemangiomas (>5)
|
Visceral involvement (especially liver), hypothyroidism
|
Liver ultrasound; if liver hemangiomas are present obtain TSH, T4, reverse T3
|
*In addition to evaluation by Pediatric Dermatology or other specialists.
Commentary from Pristine Lee, M.D., Pediatric Dermatologist:
Hemangiomas should be separated into the categories of those that need treatment and those that do not. In general, this division will guide referrals: IH with functional or life threatening potential, those that cause pain, and those that could lead to scarring or disfigurement should all be referred. Examples of specific scenarios that should be referred immediately include any segmental hemangiomas, facial hemangiomas, lesions in the perineum (as they often ulcerate and can lead to significant pain), any located on the lip or nasal tip (as these can be severely disfiguring) or any causing pain or with ulceration/scar. There are many other cases, outside of those examples, that may require treatment and I am always available if you have questions or concerns.
Timolol is a great medication, but it is not without adverse events. There is some degree of systemic absorption, although the exact amount is uncertain. Timolol is also 8 times as potent as propranolol, so even a small amount of absorption can be significant. Parents should be counseled on the potential for bradycardia, hypotension and hypoglycemia and warn against overuse. It is best used on superficial hemangiomas as it does not have a significant impact on the deeper components. Typically I do not recommend treatment for superficial hemangiomas as they mostly self-resolve without significant residua.
Given the variability and complexity of hemangiomas, patients should be referred to a pediatric dermatologist prior to initiation of therapy (topical or systemic).
This is a fascinating time to be involved in hemangioma care as there has been an incredible surge in research and knowledge. Even with all the developments, most infantile hemangiomas are still the same ones you have been taking care of for years. I hope I can be a supplement whenever you need me and thank you for allowing me to participate in the care of your patients!
Below is an AVS handout that I give families whose children have Infantile Hemangiomas. Please feel free to use as needed.
HEMANGIOMAS
WHAT ARE HEMANGIOMAS?
Hemangiomas are collections of extra blood vessels in the skin. They are a common birthmark and are present in up to 10% of healthy full term newborns. They may not be visible at birth, but rather develop in the first few weeks of life. Initially they may look like a reddish-blue skin marking before they grow and become more apparent.
Hemangiomas take a special natural course: Once they are present, they show rapid growth for 6-12 months (proliferative phase). Then, they tend to stay stable with very little change for several months (plateau phase), before they slowly start to shrink (involution phase).
Though it is difficult to predict how one particular hemangioma is exactly going to behave, it is important to remember this natural course, especially during the time of rapid growth. We understand that this is very worrisome to parents, and we would like to follow your child closely during those months and provide the needed support! The first signs noted when the hemangioma starts to resolve are a change of color from bright red/blue to grayish and no further increase in size. It may take months or years for the hemangioma to completely go away, but the cosmetic result at the end is usually excellent without any treatment. As a rule of thumb, clinical experience has shown that by age 3 years, 30% of hemangiomas have completely resolved; by age 5 years, 50% and by age 9 years, 90% will have gone away spontaneously.
CONCERNS ABOUT HEMANGIOMAS
Since hemangiomas can occur anywhere on the body and come in all shapes and sizes, there are some situations when they may cause problems and may need treatment.
Location is an important factor. If a hemangioma is found near the eye, nose, mouth, ear or groin/buttocks, it may cause pressure and interfere with the normal function of important body parts. It may cause problems with vision, breathing, feeding and toileting.
Ulceration can occur during the rapid growth phase of a hemangioma. If this happens, it is often painful, will leave a scar and may get infected.
Bleeding of the hemangioma may happen, particularly if the area has been accidentally hit. Since a hemangioma is made up of many extra blood vessels, it tends to bleed heavily and this can be extremely frightening to the parents. It is important to apply firm pressure to the area which will stop the acute bleeding in most cases!
If any of the situations mentioned above occur, we would like to hear about it and see your child again! There are different treatment options and combination of treatments available, which we would discuss with you in each individual situation.
** Permanente Medicine Today will be sponsoring a videoconference on Pediatric Hemangiomas on August 10th, 2012. **
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