Hemangioma treatment
Treatment
The timing of treatment is an important issue. There are no hard and fast rules and unfortunately, the timing is often dictated by the beliefs of the physician. It is important to realize that the early years of a child's life are the formative years of his/her psychological development. Clearly, disfigurement can adversely affect this. For this reason, we believe that early intervention is warranted. This must however be carefully weighed against the likelihood of complete involution (regression) of the hemangioma. Furthermore, the result of early intervention should leave a result that is as good as or better than the result of natural involution. This is clearly a difficult decision that should not be taken lightly. We advise the parents of the child to seek professional help and this should be given by several physicians. Unfortunately, this can be confusing since opinions will vary. Remember, these are only opinions, and nothing more.
Complications such as ulceration, congestive heart failure and failure to thrive clearly warrant early intervention. A hemangioma that interferes with a function such as speech or feeding should be treated early. The same applies to a hemangioma that could potentially block the child's airway.
There are several treatment modalities. Each has a role in the management of hemangiomas. The choice of modality should be determined by the lesion.
Systemic and locally injected steroids
The mechanism of steroids is unknown.
Steroids appear to affect the growth of hemangiomas and in some cases, can shrink the hemangioma. These drugs can be given systemically (by mouth) or they can be injected into the substance of the hemangioma (intra-lesional administration). In general, systemic steroids are more useful for the treatment of segmental hemangiomas and intra-lesional steroids are more useful for focal hemangiomas. The major advantage of intra-lesional injections is the reduction in systemic side effects.
Steroids have many side effects and for this reason, we prefer to limit the child's exposure to this potentially harmful drug. A child on steroids should be carefully monitored and although there are exceptions, we prefer to limit the child's exposure to three months of continuous steroid use.
One of the major disadvantages of steroid treatments is rebound growth. A high proportion of lesions will re-grow after treatment has been stopped. This usually prompts the physician to restart treatment and this can prolong the term of treatment. Another disadvantage is the rare but potentially dangerous side effect known as Addisonian crisis. Since our bodies make steroid which is necessary for certain important metabolic functions, the administration of a high dose, for a prolonged period (greater than 21 days), will stop the adrenal glands from manufacturing steroid. In times of stress these substances are essential for survival. When the child is exposed to stressful situations such as an infection, trauma or fever, the child will not produce these essential substances. For this reason, any child on steroids or any child who has been on steroids within the last six months should receive a stress dose.
Vincristine
Vincristine is a chemotherapeutic agent that has become popular especially for Kaposiform Hemangioendotheliomas and Hemangiomatosis with liver involvement. It is given through a central line weekly. This drug has been part of several pediatric chemotherapeutic regimens and appears to have far fewer side effects than steroids. Its use was popularized recently for the treatment of children who were having difficulty weaning off steroids as well as for children whose hemangiomas were resistant to steroid treatment.
Propranolol
Propranolol is an antihypertensive drug that has been found to be active against hemangiomas. This is a recent finding that has caused much excitement in this field. The drug's effect appears to be active during both the proliferative phase (active growth) and the involution phase (regression). We have recently treated patients as late as two to two and a half years of age with Propranolol and we are surprised to see an effect. The mechanism of action remains unknown and to date the only side effect documented appears to be a sudden drop in the blood glucose level of the child. This is usually seen when the child misses a meal. For this reason, we usually advise the parents to give the drug after a meal. If for some reason the child does not consume a sufficient quantity of food, the parents are then instructed to skip that dose. A make-up dose is not required. In this way, we have to prevent a drop in the blood glucose level.
We usually treat children with focal hemangiomas until about eight to nine months of age. This will hopefully prevent rebound growth. Children with segmental hemangiomas require a longer term of treatment due to the fact that segmental hemangiomas can proliferate for up to twenty-four months.
Pulsed Dye laser
Since the effective depth of penetration of a pulsed dye laser is minimal, laser is only appropriate for the superficial hemangiomas or the superficial component of a compound lesion. Early treatment is preferable, since we believe that early elimination of the hemangioma will allow collagen to regenerate and the skin texture will be more normal.
At some centers, a Nd:YAG laser is used to treat the surface as well as the deep component. In the right hands, this can be effective. However, the injudicious use of interstitial treatment with a Nd:YAG laser can result in significant complications. The standard of care for hemangiomas still remains a pulsed dye laser. Several other lasers are used from time to time but unfortunately these appear to carry a higher risk of scarring. While in experienced hands this may not be so, we typically do not recommend these other lasers.
Surgery
Surgical resection of hemangiomas is possible. It is important to realize that there is no text describing these procedures. The experience and past results of the surgeon are important.
Since hemangiomas are vascular tumors, the risk of severe blood loss is a possibility but in experienced hands, this risk is negligible..
Whether or not surgery is indicated will depend on a number of factors. In general, if there is a complication best treated with surgery or if it is likely that the outcome of spontaneous regression or medical management is not likely to leave a satisfactory outcome, then surgery should be considered.
