Medical Management of Haemangiomas

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Medical Management of Haemangiomas

• Dr Anne Halbert
• Department of Dermatology
• Princess Margaret Hospital

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Haemangioma

• The most common benign proliferative tumour of
  infancy
• One or more lesions can be found in 10-12 of
  infants aged 12 months
• The vast majority require no treatment

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Potential Complications

• Ulceration
• The most common complication (15)
• Particularly prevalent in the nappy area and on
  the lip
• Painful
• Inevitably heal with scarring

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Ulcerated Haemangioma
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Complications of Haemangioma

• Functional obstruction
• Eye
• Astigmatic and refractive errors
• Amblyopia and blindness
• Nose
• Airway

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Visual Obstruction
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Visual Obstruction
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Airway Compromise

• Nasal distortion

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Airway Compromise
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Systemic Involvement

• Disseminated neonatal haemangiomatosis

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DNH
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DNH
haemangiomas
Thalamic lesion
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DNH

• Very high mortality
• Liver is the most commonly affected organ
• Risk of high output congestive cardiac failure
• Babies with numerous miliary haemangiomas need to
  be screened early and often for the development
  of visceral lesions

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Systemic Involvement

• Contiguous Extension

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Contiguous Extension
aorta
haemangioma
Spinal cord
haemangioma
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PHACE Syndrome

• P posterior fossa abnormalities
• H haemangioma
• A arterial abnormalities
• C cardiac defects
• E eye abnormalities

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Kasabach Merritt Syndrome

• Usually a rapidly proliferating
  haemangioendothelioma
• Platelet consumption early in life
• Develop disseminated intravascular coagulation
• High mortality rate
• Beware a bruised appearance

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Kasabach Merritt Syndrome
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Potentially Permanently Disfiguring Haemangiomas

• Large facial haemangiomas which may involute
  leaving altered skin texture and fibrofatty
  residuum
• Haemangiomas distorting cartilage of nose or ear

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Post Involution
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Treatments

• Pulsed Dye Laser
• Treatment of choice for ulcerated haemangiomas
• May help switch off proliferative phase in very
  superficial lesions
• Useful after involution, to clear away residual
  telangiectasia

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Treatments

• Corticosteroids
• Potent topical steroids
• Intralesional steroids
• Useful for localized facial lesions
• 20-40 mg/ml triamcinolone or Celestone Chronodose
  repeated 6-8 weekly
• Technically difficult risk of ulceration
• Avoid around the eye (central retinal artery
  occlusion)

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Treatments

• Systemic Corticosteroids
• First line treatment for the prevention of
  functional obstruction, visceral haemangiomatosis
  and K-M syndrome
• 2 mg/kg/d as a single morning dose
• Usually well tolerated
• Treatment lasts 8-12 weeks

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Pre-systemic steroids
After 2 wks of steroids
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Systemic Corticosteroids

• Adverse Effects
• Initial irritability in 75
• Reflux
• Temporary reduction in growth (no permanent
  effect)
• HPA axis suppression
• Delay vaccinations

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Systemic Treatments

• Interferon Alpha
• Used in conjunction with systemic steroids for
  life threatening complications
• 1 million units/m2 /day SC initially
• Anti-angiogenesis also speeds involution
• Adverse effects include neutropenia, abnormal
  LFTs and spastic diplegia

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Systemic Treatments

• Vincristine
• Cyclophosphamide

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Thank you