SAN FRANCISCO High-dose oral steroid treatment can make an ulcerated hemangioma worse, and nobody really knows what to do when that happens, according to an online survey of 77 pediatric dermatologists.
The January 2009 survey of Society for Pediatric Dermatology members provides a snapshot of current management practices for ulcerated hemangiomas, which are guided more by anecdotal reports and clinician intuition than by trials and evidence, Dr. Annette Wagner said at a meeting of the Society.
Almost 80% of respondents said they see one to five patients each month with ulcerated hemangiomas and others see more. Most believe that each of several treatments are at least somewhat effectivebarriers, antibiotics, oral steroids, debridement, or off-label topical becaplermin gel (Regranex). Approximately 40% said oral propranolol can help.
Most of those surveyed rated topical steroids or topical imiquimod as ineffective, added Dr. Wagner, a pediatric dermatologist at Northwestern University, Chicago.
When asked if high-dose steroids worsen ulcerations, more than half said they had seen this rarely, and approximately 5% said it was a frequent problem.
"There's always a question in my mind" about the possibility of high-dose steroids worsening ulcerated hemangiomas, and the findings confirm that this does happen, Dr. Wagner said.
When steroids do worsen an ulceration, close to half of physicians surveyed increased the dose, approximately a quarter of them decreased the dose, and another quarter make no changes.
On average, the most common first-line treatment is a barrier with a topical antibiotic. "When that doesn't work," she reported, "we use oral antibiotics," the survey findings suggest.
Pulsed dye laser is the favored next-line treatment, followed by oral steroids, then Regranex. "Those are the mainstays of how we are managing ulcerated hemangiomas," she said.
Vaseline gauze is the preferred dressing, with nearly as many favoring DuoDERM, and a small proportion preferring Mepitel, a nonadherent silicone dressing.
The top choice in antibiotics was metronidazole gel (MetroGel), followed closely in popularity by mupirocin. Most respondents said they do not use propranolol to treat ulcerated hemangiomas; of those who do, most use it rarely.
Close to a third of respondents do not treat with pulsed dye laser. Of those who do, half use it rarely.
More than 40% of respondents do not use Regranex to treat ulcerated hemangiomas. Those who do use it were more likely to prescribe it rarely than frequently.
To Dr. Wagner, this suggests Regranex is underused, given the benefits she's seen with it.
Most respondents said they rarely or never debride ulcerated hemangiomas, and some even suggested that the ulcer's crust should be left on for pain control. "I completely disagree," she said. "You need to get the wound to heal, so you need to get the crust out."
Those who do debride are most likely to do mechanical debridement in the office, while approximately a third would have the patient apply peroxide at home, and fewer would apply peroxide in the office.
The ulcerations take 28 weeks to heal, on average, with most healing in 24 weeks, responses suggested.
Dr. Wagner reported having no potential conflicts of interest related to these topics.