Medical Medical Management of Management of HaemangiomasHaemangiomas
Dr Anne HalbertDr Anne Halbert
Department of DermatologyDepartment of Dermatology
Princess Margaret HospitalPrincess Margaret Hospital
HaemangiomaHaemangioma
The most common The most common benign proliferative benign proliferative tumour of infancytumour of infancy
One or more lesions One or more lesions can be found in 10-can be found in 10-12% of infants aged 12% of infants aged 12 months12 months
The vast majority The vast majority require no treatmentrequire no treatment
Potential Complications Potential Complications
UlcerationUlceration The most common The most common
complication (15%)complication (15%) Particularly Particularly
prevalent in the prevalent in the nappy area and on nappy area and on the lipthe lip
PainfulPainful Inevitably heal Inevitably heal
with scarringwith scarring
Ulcerated HaemangiomaUlcerated Haemangioma
Complications of Complications of HaemangiomaHaemangioma
Functional obstructionFunctional obstruction EyeEye
Astigmatic and refractive errorsAstigmatic and refractive errors Amblyopia and blindnessAmblyopia and blindness
NoseNose AirwayAirway
Visual ObstructionVisual Obstruction
Visual ObstructionVisual Obstruction
Airway CompromiseAirway Compromise
Nasal distortionNasal distortion
Airway CompromiseAirway Compromise
Systemic InvolvementSystemic Involvement
Disseminated neonatal Disseminated neonatal haemangiomatosishaemangiomatosis
DNHDNH
DNHDNH
haemangiomas
Thalamic lesion
DNHDNH
Very high mortalityVery high mortality Liver is the most commonly affected Liver is the most commonly affected
organ organ Risk of high output congestive cardiac Risk of high output congestive cardiac
failurefailure Babies with numerous miliary Babies with numerous miliary
haemangiomas need to be screened haemangiomas need to be screened early and often for the development of early and often for the development of visceral lesionsvisceral lesions
Systemic InvolvementSystemic Involvement
Contiguous Contiguous ExtensionExtension
Contiguous ExtensionContiguous Extension
haemangioma
aorta
Spinal cord haemangioma
PHACE SyndromePHACE Syndrome
PP posterior fossa posterior fossa abnormalitiesabnormalities
H H haemangiomahaemangioma
AA arterial arterial abnormalitiesabnormalities
C C cardiac defectscardiac defects
EE eye abnormalities eye abnormalities
Kasabach Merritt Kasabach Merritt SyndromeSyndrome
Usually a rapidly proliferating Usually a rapidly proliferating haemangioendotheliomahaemangioendothelioma
Platelet consumption early in life Platelet consumption early in life Develop disseminated intravascular Develop disseminated intravascular
coagulationcoagulation High mortality rateHigh mortality rate Beware a bruised appearanceBeware a bruised appearance
Kasabach Merritt Kasabach Merritt SyndromeSyndrome
Potentially Permanently Potentially Permanently Disfiguring HaemangiomasDisfiguring Haemangiomas
Large facial haemangiomas which Large facial haemangiomas which may involute leaving altered skin may involute leaving altered skin texture and fibrofatty residuumtexture and fibrofatty residuum
Haemangiomas distorting cartilage Haemangiomas distorting cartilage of nose or earof nose or ear
Post InvolutionPost Involution
TreatmentsTreatments
Pulsed Dye LaserPulsed Dye Laser Treatment of choice for ulcerated Treatment of choice for ulcerated
haemangiomashaemangiomas May help switch off proliferative May help switch off proliferative
phase in very superficial lesionsphase in very superficial lesions Useful after involution, to clear away Useful after involution, to clear away
residual telangiectasiaresidual telangiectasia
TreatmentsTreatments
CorticosteroidsCorticosteroids Potent topical steroidsPotent topical steroids Intralesional steroidsIntralesional steroids
Useful for localized facial lesionsUseful for localized facial lesions 20-40 mg/ml triamcinolone or Celestone 20-40 mg/ml triamcinolone or Celestone
Chronodose repeated 6-8 weeklyChronodose repeated 6-8 weekly Technically difficult – risk of ulcerationTechnically difficult – risk of ulceration Avoid around the eye (central retinal Avoid around the eye (central retinal
artery occlusion)artery occlusion)
TreatmentsTreatments
Systemic CorticosteroidsSystemic Corticosteroids First line treatment for the First line treatment for the
prevention of functional obstruction, prevention of functional obstruction, visceral haemangiomatosis and K-M visceral haemangiomatosis and K-M syndromesyndrome
2 mg/kg/d as a single morning dose2 mg/kg/d as a single morning dose Usually well toleratedUsually well tolerated Treatment lasts 8-12 weeksTreatment lasts 8-12 weeks
Pre-systemic steroids
After 2 wks of steroids
Systemic CorticosteroidsSystemic Corticosteroids
Adverse EffectsAdverse Effects Initial irritability in 75%Initial irritability in 75% RefluxReflux Temporary reduction in growth (no Temporary reduction in growth (no
permanent effect)permanent effect) HPA axis suppressionHPA axis suppression Delay vaccinationsDelay vaccinations
Systemic TreatmentsSystemic Treatments
Interferon AlphaInterferon Alpha Used in conjunction with systemic Used in conjunction with systemic
steroids for life threatening steroids for life threatening complicationscomplications
1 million units/m1 million units/m2 2 /day SC initially/day SC initially Anti-angiogenesis; also speeds Anti-angiogenesis; also speeds
involutioninvolution Adverse effects include neutropenia, Adverse effects include neutropenia,
abnormal LFTs and abnormal LFTs and spastic diplegiaspastic diplegia
Systemic TreatmentsSystemic Treatments
VincristineVincristine
CyclophosphamideCyclophosphamide
Thank youThank you