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8/2/2019 P32 Children Talk Compressed Dich 2

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Treatment of InfantileHemangiomas and Scars

iu tr u mch nh nhi v soProf. Rox Anderson MD

Harvard Medical School (Boston, USA)Vietnam VAC (here)


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Vascular Lesions of the Skin

Tumors(proliferation)

Malformations

Hemangiomas KHE Tufted PyogenicAngioma Granuloma

Lymphatic Venous Arteriovenous MixedInfantile Congenital

RICH NICH

(Small vessel)

(Large vessel)

L.C. Portwine stain Spider Angioma,HHT

KlippelTrenaunay


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GLUT-1GLUucose Transporter(endothelial cells)

Lewis-Y antigen(pericytes)

Diagnostic markers

for infantile

hemangiomas

Similar toPlacenta


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Typical Course

White spotin first week of life

Small red dot(s) appear at ~10 days

Rapid growthphasefor 3-12 months Ulcerate(~ 20%) pain, infection, scar

Stationaryphase (growth + apoptosis)

Involution(~ 60% by first grade) Fibro-fatty scarring (~ 30% require tx)


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Neglect is often not Benign

Psycho-social impact on family

~ 20% will ulcerate (pain, infection)

~ 30% will need surgery(1% of everyone)

Mouth and neck airway

Eyelid visual impairment

Nose, lips disfigurement


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Treatment Options forInfantile Hemangioma

Make the right diagnosis At onset ?? (no good studies)

Proliferative and early stationary phase Propranolol (NEJM 358:2649, 2008) Oral or intralesional corticosteroids Imiquimod 5% topical QD

Low-fluence pulsed dye laser Residual Staged excision Fractional resurfacing lasers


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Propranolol


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GLUT-1 positive retroorbital lesionPropranolol 2 mg/kg/day x 5 days, then oral x 6 wksComplete clinical resolutionMRI normal at 3 months


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Propranolol

1st choice therapy for I.H. Non-selective b blocker Oral dose 0.5 2 mg/kg per day

Monitor for Hypotension (bradycardia)

Hypoglycemia (give doses with food)

~75% of tumors respond rapidly Hyperkalemia is possible

1-4 months, typical duration of treatment


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Topical b-blockers

Timolol 0.5 - 1% aqueous solution, orgel-forming solution

Used as an eye drop, for glaucoma

Twice daily application is effective for I.H.

No side effects have been reported

Prospective trials not yet available


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Infantile eyelid hemangioma ~ 2% of all children Amblyopia and astygmatism in


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Before5-10-11

6-08-11

After6-08-11


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What triggers the involutionof Infantile Hemangiomas?

Anti-angiogenesis agents INFa , corticosteroids, PDGF

Pro-apoptosis agents: b blockers Immune stimulation Imiquimod

Pulsed dye laser

Damages microvessels Activates platelets Causes vasculitis 4-7 J/cm2, 0.4 ms or less


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Pre-treatment Post steroid

Post PDL x 2


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Before5-10-11

After6-08-11


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Radioactive P32 for Babies!?

Beta emitter

Old French treatment for

hemangiomas Abandoned in ~1960, but

War

Trade embargo

Left OverFrom the

FrenchFor 40 years


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Vietnamese child with hemangioma treated with 32P

Morphea-like dermal sclerosis (scarring), with loss of adnexa (40X)

Dermal Sclerosis with Increased stromal cells (100X)

23Thuy Phung, MD PhD

40x40x 40x

100x 100x


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Vietnamese child with hemangioma treated with 32P

Epidermal hyperplasiawith LSC-like changes

(200X)

Vascular ectasia in the papillarydermis (400X)

Radiation fibroblasts in the dermis(400X)

24

200x 400x 400x

Radiation Damage

Thuy Phung, MD PhD


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Please, stopthe use of P32for children withhemangiomas!


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How can we help peopletreated with P32?

Replace the skin?

Epidermis

Dermis

Improve the scar? Fractional laser


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Replace the epidermis?

Suction blister transfer graftingSimilar to vitiligo treatment

How to treat a large area?Fractional suction blister grafting


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Improve the scarring (dermis)


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Atrophy after hemangioma involution

Pre After

5 Fractional Laser Treatments


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Tissue Shrinkage

Ablative Fractional Lasers

Depth, widthare energydependent

Shrinkage(CO2 > erbium)


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100 mm100 mm100 mm

Healing summary: Skin Remodeling

Multiple subjects treated at 20 mJ pulse energy

Immediately 48 hours 7 days 1 month 3 month

100 mm100 mm

Trauma Scars


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Trauma Scars

Respond to ablative or non-ablative fractional

Ablative + topical steroid

excellent synergy Jill Waibel, MD and Chad Hivnor, MD

Courtesy of Jill Waibel, MD 3 x non-ablative laser


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Scar from a burn20 years ago

2 weeksfollowing two

fractionalablative lasertreatments

J. Waibel, M.D.


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Baseline

3 months

following 5 non-ablative

treatments


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Fractional Laser Treatments

Keep the skin cool during treatmentUse cold air or ice Use low treatment Density (


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Dosimetry

Pulse energydepth of treatment Set pulse energy to match the depth

of the scar Atrophic or hypertrophic? 0.4 mm to 2 mm deep 10 to 50 mJ energy per pulse

Density For scars, typically 5-10% density


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Thank you

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