Pediatric Hemangiomas
At Mount Sinai, we have a lot of experience dealing with pediatric hemangiomas. Hemangiomas are benign (non-cancerous) tumors of blood cells that often show up as "birthmarks." Scientists do not know why they occur, but we do know that they affect girls three to five times more often than boys and are linked with prematurity, low birth weight, and twin pregnancy. While hemangiomas can appear anywhere on the body, more than 80 percent involve the head and neck, including areas around the mouth, eyes, tip of nose, and cheek.
Most hemangiomas are quite small and harmless, but some are quite large and problematic. They can cause ulceration, scarring, eye complications, airway obstruction, failure to thrive, and cardiac failure.
Hemangiomas pass through two stages in their life cycle, growth (proliferation) and shrinkage (involution or regression). They usually begin to grow around the first year of life. They can shrink anywhere from year 2 to 12. Some hemangiomas completely disappear.
There are two major types of hemangiomas:
- Focal hemangiomas are the most common. They usually grow as solitary tumors in specific sites, which we call sites of predilection. Focal hemangiomas are usually in the skin or just beneath it. They can be entirely superficial (in which case they are a reddish color), deep (in which case they are a bluish color), or compound with both superficial and deep characteristics.
- Segmental hemangiomas involve one or more segments of the face and body, and they grow more broadly than focal hemangiomas. Segmental hemangiomas grow rapidly in the first few weeks of life and can continue to grow for up to two years. They turn into ulcers more often than focal hemangiomas and can be damaging for the area they affect.
Treatment Options
Children’s early psychological development is critical and disfigurement can hurt this process. For this reason, we believe that early intervention is appropriate, but we must weight it carefully against the possibility of the hemangioma disappearing on its own. We discuss this thoroughly with the child’s parents and guardians. We also want to avoid any hemangioma complications such as ulceration, congestive heart failure, failure to thrive, airway obstruction, and impairment of speech or feeding.
We have several approaches to managing and treating hemangiomas:
- Medical management refers to the use of medications, such as steroids (both oral and injectable), chemotherapy, and propranolol (an antihypertensive medication). We monitor all patients closely as they undergo medical management.
Steroids appear to affect the growth of hemangiomas and can sometimes shrink them. We provide these medications systemically (by mouth) or inject them directly into the hemangioma (intra-lesional administration). Generally, systemic steroids work better on segmental hemangiomas, and intra-lesional steroids are more effective for focal hemangiomas. Intra-lesional injections are particularly helpful in reducing systemic side effects. Steroids can have concerning side effects, so we use them very conservatively and with careful monitoring.
Vincristine is a chemotherapeutic agent that we use for certain kinds of hemangiomas. We administer it through a central intravenous line once a week. It has far fewer side effects than steroids.
Propranolol is an antihypertensive drug that works well during both the active growth phase and the shrinkage phase of the hemangioma.
- Laser treatment uses intense and powerful light waves to treat hemangiomas. We use different kinds of lasers for various types and stages of hemangiomas. Usually, we need to administer several laser treatments, which we do under anesthesia. Our goal is to restore the normal color and texture of the skin by destroying the dilated blood vessels. We use lasers on lacerated hemangiomas as well.
- Surgery is an option that we reserve for lesions that are unlikely to shrink spontaneously or that have not responded to medical management. Since hemangiomas are vascular tumors, the risk of severe blood loss is a possibility, but, in the experienced hands of our surgeons, this risk is negligible. We also treat some hemangiomas complications surgically, including eyelid hemangiomas, ulceration, and airway obstruction.