SPOKANE, WASH. — The top three reasons to consider treatment of a neonatal hemangioma are the same as the top three determinants of value in real estate: location, location, and location, explained Howard B. Pride, M.D.
While most neonatal hemangiomas will involute and resolve spontaneously, some require treatment, Dr. Pride said at the annual Pacific Northwest Dermatological Conference:
▸ Hemangiomas in the “beard” area of the face can grow to compromise the airway.
In one study, children with extensive hemangiomas in the beard area had a 63% chance of airway involvement, and 40% needed tracheotomy (J. Pediatr. 1997;131:643–6). In a separate study of “parotid” hemangiomas (a term often used synonymously with “beard-area hemangiomas”), 59% ulcerated, 26% had airway involvement, 7% required tracheotomy, and 70% required systemic treatment (Plast. Reconstr. Surg. 2004;113:53–60).
▸ Hemangiomas near the eye, while not life threatening, can be vision threatening, said Dr. Pride of Geisinger Medical Center, Danville, Pa.
If the hemangioma grows large enough to block vision during a critical period of neural development, the child's cortical vision centers may never develop normally.
Even if the hemangioma goes on to resolve spontaneously, that child will suffer permanent vision damage.
▸ Hemangiomas on the nasal tip can have bad cosmetic outcomes after they resolve.
“Sometimes, fairly banal hemangiomas [on the nose] will leave very significant cosmetic problems,” Dr. Pride said at the conference, which was sponsored by the Washington State Dermatology Association.
▸ Lip hemangiomas can also have bad cosmetic outcomes, although the chances of this happening are somewhat less than when the nose is involved. The skin on the lip has a degree of laxity, and therefore there's a smaller risk of scarring.
▸ Hemangiomas on the hand or fingers can have functional as well as cosmetic consequences.
▸ Hemangiomas in the diaper area, even fairly small ones, “have an unbelievable propensity for ulceration and are really bad,” Dr. Pride said.
▸ Whether to treat pedunculated hemangiomas is a subject of debate.
While some plastic surgeons prefer to fix residual cosmetic defects after the hemangioma resolves, others recommend early surgical excision. Hemangiomas that grow like a mushroom, with a large mass on a narrow stalk, are especially good candidates for early intervention, Dr. Pride said.
When dealing with any pedunculated hemangioma, “get the surgeons involved early and then let them walk through the nuances of whether it should be done early or late,” he said.
▸ Diffuse neonatal hemangiomatosis is a serious condition, since it's often accompanied by visceral hemangiomas in the liver, lung, brain, or GI tract.
The presence of five or more cutaneous hemangiomas should trigger an ultrasound examination of the infant, hemoccult stools, and possibly a chest x-ray if lung involvement or congestive heart failure is suspected.
Untreated, this condition has a 75% mortality rate.
▸ PHACES syndrome is another serious hemangioma-related condition requiring treatment.
It's named from an acronym of its main features: posterior fossa malformations; hemangiomas of the cervicofacial area; arterial anomalies, especially in the CNS; cardiac anomalies, sometimes including coarctation of the aorta; eye abnormalities; and sternal or abdominal clefting.
This 5-week-old child has a large hemangioma around the eye. The lesion was treated with prednisone for 4 months and responded well to the therapy. Courtesy Dr. Howard B. Pride