The first thing you should realize is that there are options for treatment. There is no reason in this day and age to accept that the only option available is to ‘leave it alone’ and wait for the hemangioma to ‘go away’.
Secondly, the most appropriate treatment plan needs to be individualized for each patient and each lesion. Therefore, similar lesions in different patients may be treated differently. Likewise, a given child may have more than one hemangioma and each of those may be treated differently.
There are various factors that come into play when deciding what treatment is best – whether the hemangioma is proliferating or involuting; whether it is superficial, deep or compound; the location of the lesion and the age of the child. In general, there are four potential treatment options which may be used singly or in combination.
Observation is included as a treatment option because sometimes it is appropriate to see what happens. Different from the ‘leave it alone and it will go away’; it is a conscious decision to use a predetermined period of time to observe how the birthmark changes.
Now in December 2016, the American Academy of Pediatrics recommends that all four-week-old infants with a visible birthmark be referred to a vascular birthmark specialist, so action can be taken quickly if needed.
For example, if a one-month old infant develops a deep hemangioma of the upper back, it is uncertain how much the lesion will proliferate. The lesion would be observed for a couple of months to see what happens and give the infant the opportunity to grow and gain weight.
If after a couple of months there is little change or the hemangioma is proliferating slowly it is possible that observation should go on for a couple more months.
On the other hand, if the lesion dramatically changes, the baby would be seen earlier and other options should be considered.
This powerful medicine is the mainstay of medical treatment for hemangiomas, replacing steroids as the first line medical treatment for infantile hemangiomas. The goal is to slow down the growth of the lesion. Propranolol is a beta-receptor blocker – it’s effects in general are to decrease heart rate, decrease blood pressure, relieve anxiety and various other uses. However, for infantile hemangiomas it has been found to decrease the rate of proliferation and increase the rate of involution. The doses at which propranolol is used for hemangiomas is much lower than for other conditions – therefore the side effects are extremely rare. Propranolol is also available as Hemangeol (made by Pierre-Fabre Pharmaceuticals).It is the only FDA approved version of propranolol for the treatment of infants with infantile hemangioma. It is formulated specifically for this use.
Oral or systemic steroids are used for rapidly proliferating lesions in a cosmetically sensitive area or one causing functional impairment.
The rare lesions that are life-threatening or do not respond to propranolol are always treated with steroids and, occasionally, other medicines. Due to steroid side effects, the use of this medicine is carefully monitored.
Traditionally, lesions around the eye have been treated with these injections, although surgery is often a better option, in our opinion.
The goal of laser treatments is to completely remove the lesion, set the stage for further treatments, treat complications or treat the inevitable broken blood vessels (telangiectasias) left behind as a hemangioma involutes.
The pulsed dye laser (PDL) with a dynamic cooling device is the mainstay for treatment of the superficial vascular component of the hemangioma. It can be used to slow the proliferation, reduce the redness and set the stage for other treatments.
Multiple treatments are typically needed. Depending on the lesion, age of the child and location, the treatments may be done with or without anesthesia. The least traumatic and safest way is chosen for each patient. The PDL can be used to help heal hemangiomas that have ulcerated (the skin has broken open).This is particularly helpful for lesions in the diaper area.
The Nd:YAG laser is used for treating the deep component of hemangiomas involving the oral cavity, larynx (voice box) and occasionally the skin. This laser must be very carefully used by experienced physicians. The KTP laser is most commonly used for airway lesions.
Resurfacing lasers such as the CO2 and Erbium are used to help with scar revisions and improving the texture of the skin after involution. In children, these must be used very carefully.
Along with lasers, surgery achieves high results in most of our patients. There are many misconceptions about operating on hemangiomas – the risk of hemorrhage in particular – that we are trying to educate physicians about.
Unfortunately, there are physicians on TV and through lectures, have scared families into believing that only a handful of surgeons are capable of doing these surgeries.
The truth is that many doctors haven’t learned or had the opportunity to educate themselves more about these procedures. The Hemangioma Foundation is committed to training doctors to successfully operate on these lesions so families will not have to travel such great distances for treatment. In general, children can be operated on successfully with a minimal amount of blood loss.
Similar to lasers, the goal of surgery is to remove the lesion completely set the stage for other treatments, or correct what is left after involution. Lesions are operable throughout proliferation or involution.
Timing is influenced by the child’s age and weight as well as the impact the hemangioma is having on function.
For example, a rapidly proliferating compound hemangioma of the upper eyelid that is beginning to impair vision may be removed at an earlier point than a deep hemangioma of the back which has begun to involute. Surgeries may be done in stages in certain cases in order to get the best cosmetic result. Scar revisions, in particular, need to be done judiciously in young patients.
Often a combination of treatment options are used. Superficial component of a compound hemangioma of the nasal tip may be treated with the PDL in preparation for surgery of the deep component. A deep hemangioma of the orbit that is pushing on the eyeball could be treated with steroids while the PDL is used for a separate superficial lesion in the same patient.
Many of the same modalities that are used for hemangiomas are used in the treatment of malformations. There are some important differences however. Malformations are true developmental abnormalities of the involved structures.
Any part of the malformation that is left behind after treatment has the potential for growing. It is very important that the goals of the treatment are clearly established. It is not always possible to remove the entire malformation surgically without causing harm to normal structures. A more conservative approach may be chosen when multiple treatments may be necessary or that another treatment tool, such as embolization or sclerotherapy, may be needed.
Embolization and sclerotherapy are procedures done by an Interventional Radiologist. These procedures close down the blood supply of a malformation (venous or arterio-venous malformations, for example) prior to surgery or can be a primary treatment option. Special medicines, different coils, sponges and other materials are used as treatment methods. These treatments can scar down the malformation (such as with lymphatic malformations). The interventional radiologist does studies prior to surgery to map out the malformation.
The most common malformation for which lasers are used is the port wine stain. For these, the pulsed dye laser (PDL) with a dynamic cooling device is the currently the best treatment. Early treatment of port wine stains is advocated to try to close off the abnormal vessels.
Even after this malformation clears, touch up treatments may be needed in the future. There is currently no way to permenantly remove a port wine stain. However, it is definitely worth treating in order to avoid complications such as ‘peppercorns’ or ‘cobblestones’.
Once these areas of thickening occur they are more difficult to treat. The GentleYAG and resurfacing lasers are useful in these instances as well. Likewise, we try to prevent the overgrowth of tissues by using the laser early on. Surgery is useful for port wine stains to reduce the size of structures that have thickened such as the lips, eyelids and nose.
Steroids are occasionally used treating malformations to reduce swelling during flare-ups. For example, lymphatic malformations can enlarge during a viral illness or venous malformations may get ‘clogged’ with calcification causing pain and swelling – steroids may be used as a temporary measure to treat these problems. However, unlike with hemangiomas, the steroids are not treating the malformation itself.