Where to refer patients with high-risk hemangiomas?

Referral of Patients with High-Risk Hemangiomas

Patients with high-risk infantile hemangiomas should be referred to a hemangioma specialist as soon as possible for prompt evaluation and management to prevent adverse outcomes. 1

Identifying High-Risk Hemangiomas

High-risk infantile hemangiomas (IHs) that warrant specialist referral include:

1. Location-based risk factors:

   • Periocular hemangiomas (risk of astigmatism, strabismus, amblyopia) 2
   • Airway hemangiomas (risk of airway obstruction) 2
   • Large facial hemangiomas (risk of disfigurement) 1
   • Lip hemangiomas (risk of ulceration and permanent scarring) 1
   • Segmental lumbosacral or perineal hemangiomas (risk of ulceration and association with underlying structural anomalies) 1

2. Complication-based risk factors:

   • Ulcerated hemangiomas (risk of pain, bleeding, infection) 1
   • Hemangiomas causing functional impairment 2
   • Multiple cutaneous hemangiomas (≥5, risk of hepatic hemangiomas) 1
   • Segmental hemangiomas associated with LUMBAR syndrome (lower body hemangioma, urogenital abnormalities, ulceration, myelopathy, bony defects, anorectal malformations, arterial anomalies, and renal anomalies) 1

Timing of Referral

The timing of referral is critical because:

• Most rapid growth occurs between 1-3 months of age 2
• Growth typically stops by 5 months of age 1
• Early intervention during the proliferative phase can prevent permanent skin changes and functional impairment 1
• Delaying referral beyond the critical growth phase can lead to missed opportunities for effective treatment 1

Specialist Types for Referral

Depending on the specific concern, referral should be directed to:

• Dermatologist with expertise in vascular birthmarks (for most cutaneous hemangiomas)
• Ophthalmologist (for periocular hemangiomas) 2
• Otolaryngologist (for airway hemangiomas)
• Neurosurgeon (for segmental lumbosacral hemangiomas with suspected spinal involvement) 1
• Multidisciplinary vascular anomalies clinic (for complex cases or those with syndromic associations) 3

Expediting Referrals

For high-risk hemangiomas, expedited referral pathways should be utilized:

• Request priority appointments, specifically mentioning the high-risk nature of the hemangioma 1
• Consider telemedicine triage with photographs to reduce wait times (one center reduced age at first evaluation from 5.9 to 3.5 months using teledermatology) 1
• Educate office staff to prioritize appointments for infants with high-risk IHs 1

Imaging Considerations

• Do not routinely perform imaging unless:

  • The diagnosis of IH is uncertain
  • There are 5 or more cutaneous IHs (screen for hepatic involvement)
  • Associated anatomic abnormalities are suspected 1

• When imaging is indicated:

  • Ultrasonography with Doppler is the initial imaging modality of choice 1
  • MRI may be necessary for suspected deeper structural involvement, particularly with segmental lumbosacral hemangiomas 1

Common Pitfalls to Avoid

1. Delayed referral: Waiting until complications develop can result in permanent disfigurement or functional impairment 1

2. Reassurance without risk assessment: The outdated belief that "all hemangiomas go away" can lead to missed opportunities for intervention 1

3. Failure to recognize syndromic associations: Segmental lumbosacral hemangiomas may be associated with underlying spinal dysraphism in up to 55% of cases as part of LUMBAR syndrome 1

4. Inadequate monitoring: Even if immediate referral isn't warranted, high-risk IHs require frequent monitoring during the proliferative phase 1

5. Overlooking functional concerns: Focus should be on preventing not only cosmetic issues but also functional impairment and life-threatening complications 2

By following these guidelines for timely referral of high-risk infantile hemangiomas, clinicians can help prevent adverse outcomes and optimize treatment during the critical window of opportunity.