Medical Management of Haemangiomas Dr Anne Halbert Department of Dermatology Princess Margaret Hospital

Haemangioma The most common benign proliferative tumour of infancy One or more lesions can be found in 10-12% of infants aged 12 months The vast majority require no treatment

Potential Complications Ulceration The most common complication (15%) Particularly prevalent in the nappy area and on the lip Painful Inevitably heal with scarring

Ulcerated Haemangioma

Complications of Haemangioma Functional obstruction Eye Astigmatic and refractive errors Amblyopia and blindness Nose Airway

Visual Obstruction

Visual Obstruction

Airway Compromise Nasal distortion

Airway Compromise

Systemic Involvement Disseminated neonatal haemangiomatosis

DNH

DNH haemangiomas Thalamic lesion

DNH Very high mortality Liver is the most commonly affected organ Risk of high output congestive cardiac failure Babies with numerous miliary haemangiomas need to be screened early and often for the development of visceral lesions

Systemic Involvement Contiguous Extension

Contiguous Extension aorta haemangioma Spinal cord haemangioma

PHACE Syndrome P posterior fossa abnormalities H haemangioma A arterial abnormalities C cardiac defects E eye abnormalities

Kasabach Merritt Syndrome Usually a rapidly proliferating haemangioendothelioma Platelet consumption early in life Develop disseminated intravascular coagulation High mortality rate Beware a bruised appearance

Kasabach Merritt Syndrome

Potentially Permanently Disfiguring Haemangiomas Large facial haemangiomas which may involute leaving altered skin texture and fibrofatty residuum Haemangiomas distorting cartilage of nose or ear

Post Involution

Treatments Pulsed Dye Laser Treatment of choice for ulcerated haemangiomas May help switch off proliferative phase in very superficial lesions Useful after involution, to clear away residual telangiectasia

Treatments Corticosteroids Potent topical steroids Intralesional steroids Useful for localized facial lesions 20-40 mg/ml triamcinolone or Celestone Chronodose repeated 6-8 weekly Technically difficult – risk of ulceration Avoid around the eye (central retinal artery occlusion)

Treatments Systemic Corticosteroids First line treatment for the prevention of functional obstruction, visceral haemangiomatosis and K-M syndrome 2 mg/kg/d as a single morning dose Usually well tolerated Treatment lasts 8-12 weeks

Pre-systemic steroids After 2 wks of steroids

Systemic Corticosteroids Adverse Effects Initial irritability in 75% Reflux Temporary reduction in growth (no permanent effect) HPA axis suppression Delay vaccinations

Systemic Treatments Interferon Alpha Used in conjunction with systemic steroids for life threatening complications 1 million units/m2 /day SC initially Anti-angiogenesis; also speeds involution Adverse effects include neutropenia, abnormal LFTs and spastic diplegia

Systemic Treatments Vincristine Cyclophosphamide

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