Treatment

The decision to intervene and treat the patient without an active or inevitable complication must be weighed against the fact that most hemangiomas will resolve completely or with minimal long-term sequella. For problematic hemangiomas there are multiple treatment options. The most appropriate will depend on both the location and the nature of the impending complication and the child's specific medical and social situation.

Steroids are the usual first line treatment. Typical initial doses are 2mg/kg/day of prednisilone or prednisone.8 This initial therapy is usually used for four to six weeks. A response is usually seen within 7-10 days if the therapy is effective. This dose is then tapered over the next several months, as the patient will tolerate. Rebound growth may necessitate a second course of therapy. Alternate day dosing or rest periods of several weeks may lessen troublesome side-effects such as cushingoid appearance, growth retardation, decreased appetite, and susceptibility to infection, to name only a few.

Intralesional steroid injection may be used as an initial therapy especially for orbital or peri-orbital lesions, tumors of the nasal tip, and globular tumors of the lips, ear or cheek. A 50-50 combination of long-acting (triamcinolone 40mg/ml) and short-acting steroids (betamethasone 6mg/ml) yields the best results. Three injections, at doses of 3-5 mg/kg/per procedure of triamcinolone spaced four to six weeks apart are often described. Injections of long-acting corticosteroids in a suspension in the peri-orbital location have been complicated by blindness. Great caution is needed in these locations, especially the upper lid. When effective, injection therapy usually leads to dramatic reduction in the size of the lesion within one week. In general steroid therapy (systemic or intralesional) can be summarized to be dramatically effective in one third of patients, partially effective in one third of patients, and ineffective for one third of patients.

Interferon a-2a is a comparatively new agent for the treatment of hemangiomas. Although it is effective is most cases, it is generally considered a second line drug because of cost, route of administration and potential side effects. The treatment is generally reserved for pulmonary hemangioma, life-threatening hemangioma, and diffuse neonatal hemangioma. Transient side effects include fever elevated liver enzymes and neutropenia. Spastic diplegia and other permanent neurologic complications associated with the use of Interferon a-2a have resulted in cautious application of this therapy. The typical dose is 3 million units/m2 injected subcutaneously daily. The therapy is generally administered for six to twelve months.

Laser therapy for hemangiomas is becoming widely practiced to combat mucosal lesions and cutaneous lesions with or without ulceration.

Laser debulking of mucosal lesions is the typical treatment in the United States for obstructing lesions such as subglottic hemangiomas. The goal is to reduce the size of the lesion to allow for an adequate airway. Recurrence is anticipated and the treatment is repeated, until the hemangioma stops proliferating and involutes. Various laser are employed, but all share the drawback causing a mucosal ulceration in the airway.

Ulceration is the most widely accepted indication for cutaneous laser therapy. The yellow light emitted by pulsed dye lasers is selectively absorbed by hemoglobin and melanin. In the ulcerated hemangioma the laser light does not need to pass through the skin and melain within the skin to reach the hemangioma; therefore, the risks of scarring due to absorption by melanin are thought to be decreased. Recent advances in the flash lamp-pumped pulsed dye laser, including longer wavelengths and longer pulse durations as well as dynamic cooling of the surface tissues have allowed for higher energy treatments, deeper penetration, fewer complications and better overall responses. The KTP and Nd:Yag laser have been employed for intralesional therapy by using bare fibers to deliver high energies to the deep components of the lesions. The use of these new laser technologies, although gaining in acceptance and recognition of utility, is not standardized and its use is limited to the experience of the practioner. Excision is used most widely in the involuted lesion that has been stable for 6-12 months. Baggy fibrofatty tissue is typically re-contoured for improved cosmesis. Early surgical excision of a small proliferating lesion in a location, that will almost certainly cause complications or impaired function is also clearly appropriate. Such a location would be the glabella or the lateral nasal wall. This can be done with minimal or no blood loss using routine techniques. Some surgeons also advocate early removal of facial or scalp lesions, in spite of the fact they will likely involute with good results if given time. The rationale is to avoid systemic therapy and/or to spare the child and family the anticipated psychosocial difficulty of a protracted treatment. This may well be appropriate with careful and honest family counseling.