HEMANGIOMAS

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HEMANGIOMAS

• James Hansen

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Definition of a Hemangioma

• A benign skin lesion consisting of dense, usually
  elevated masses of dilated blood vessels.

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Blood Vessel Formation

• Blood vessels are tubes of endothelial cells
  surrounded by layers of smooth muscle cells and
  connective tissue proteins, which develop as a
  result of biochemical signals between the two.
• Sometimes this communication fails and abnormal
  blood vessels form.

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Probing Vascular Disorders

• By analyzing gene mutations causing vascular
  abnormalities, much can be learned about the
  signals that are necessary to form normal blood
  vessel development.
• Many studies are examining the causes of
  hemangiomas in children and the mechanisms
  underlying their growth.

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Types of Hemangiomas

• Strawberry Hemangioma
• Cavernous (Deep) Hemangioma
• Compound Hemangioma

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Strawberry Hemangioma

• strawberry red mark found on 1 out of 10 babies
• small as a freckle or large as a coaster
• consists of small closely packed blood vessels
• 95 disappear by the time the child is 10 years
  old

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Cavernous (Deep) Hemangioma

• deeply situated red-blue spongy mass of tissue
  filled with blood found on 2 out of 100 babies
• grows rapidly in the first six months
• composed of larger, more mature vascular
  elements
• some of these lesions disappear on their own

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Compound Hemangioma

• contains both superficial and deep parts
• these are often the largest and the most
  spreading
• similar characteristics to both the strawberry
  hemangioma and the cavernous hemangioma

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Consider Treatment

• Treatment should be considered if the hemangioma.

• ulcerates
• bleeds
• causes functional impairment
• causes infection
• grows rapidly and uncontrollably
• causes psychological problems

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Treatments of Hemangiomas

• Medical
• steroid injection
• interferon alfa-2a

• Surgical
• resection
• FPDL
• YAG laser

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Medical Treatments

• Steroid Injection
• benefit in managing rapid growth or functionally
  disabling hemangiomas
• prednisone or prednisolone administered with a
  dose of 2 to 4 mg per kg per day for two to three
  weeks
• positive response to steroids is characterized by
  tactile softening, lightening color or slowed
  growth occurring within 7 to 10 days of initial
  dosage
• if no response is seen then the treatment should
  be discontinued
• side effects include cushingoid symptoms, growth
  retardation and infection

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Medical Treatments

• Interferon Alfa-2a
• benefit in inhibiting angiogenisis and stimulate
  endothelial cell prostacyclin formation, which
  prevents platelet trapping
• interferon alfa-2a is administered in daily
  subcutaneous injections of 1 to 3 million units
  per square meter of body surface area for an
  average of 7 months of therapy
• 18 of 20 infants whose lesions were resistant to
  steroid therapy responded to interferon alfa-2a
  with a 50 regression rate
• acute side effects, which are reversible, include
  fever, chills, arthralgias and retinal
  vasculopathy

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Surgical Procedures

• Resection
• surgical excision is occasionally advocated as
  the primary treatment of hemangiomas
• resection surgically removes all or part of the
  tissue
• indicated as the management of visceral lesions
  unresponsive to steroids
• used for the cosmetic revision of redundant skin
  remaining after spontaneous involution of deeper
  hemangiomas

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Surgical Procedures

• FPDL - flashlight-pumped pulsed dye laser
• treatment of choice for superficial strawberry
  hemangiomas with a response rate of 60 percent
• penetrates to a depth of 1.8mm and has a low risk
  of scarring
• local anesthetic is effective in reducing pain or
  discomfort and some bruising may occur
• several laser sessions may be needed to achieve
  optimal improvement

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Surgical Procedures

• YAG Laser
• treatment of choice for rapidly growing deep or
  mixed hemangiomas with a response rate of 75
  percent
• penetrates to a depth of 5 to 6 mm, although scar
  formation is more frequent than with the FPDL
  since the laser penetrates deeper into the skin
• requires local or general anesthesia
• not recommended in the initial treatment of
  cutaneous hemangiomas

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Conclusion

• hemangiomas may be unpredictable - they may
  proliferate, remain constant or involute
• treat when vital anatomic areas are involved or
  growth is rapid
• treat if bleeding, ulceration or infection occurs
• make use of all modalities as needed

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References

• Eisenberg, Arlene Hathaway, B.S.N., Sandee E.
  Murkoff, Heidi E. 1989. What To Expect The First
  Year.
• New York Workman Publishing Company
• Lehrer, M.D., Michael. 10/28/2001.
  Birthmarks-Red.
• April 11, 2003, http//www.pennhealth.com/ency/art
  icle/001440.html
• Lowitt, M.D., Mark H. Wirth, M.D. Fern A.
  2/15/1998. Diagnosis and Treatment of Cutaneous
  Vascular Lesions
• April 11, 2003, http//www.aafp.org/afp/980215ap/w
  irth.html
• Olsen, M.D., Ph.D., Bjorn R. 2000. The Forsyth
  Institute.
• April 10, 2003, http//www.forsyth.org/re/re_I_ols
  en.html
• American Osteopathic College of Dermatology.
  2001. Hemangiomas.
• April 10, 2003, http//www.aocd.org/skin/dermatolo
  gic_disease/hemangiomas.html

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Dedication

• This presentation is dedicated to my daughter,
  Gabriella, who was diagnosed with a hemangioma
  located on her parietal lobe at birth.