What is the treatment approach for hemangioma?

Treatment Approach for Hemangiomas

Most infantile hemangiomas (IHs) do not require treatment and will involute naturally, but propranolol is the first-line treatment for high-risk or complicated hemangiomas that require intervention. 1, 2

Classification and Natural History

Hemangiomas are classified into distinct types:

• Infantile hemangiomas (IHs): Most common vascular tumor of childhood (5% of infants)
• Congenital hemangiomas: Present at birth (RICH - rapidly involuting, NICH - non-involuting)
• Vascular malformations: Structural anomalies rather than true tumors

The natural history of IHs follows a predictable pattern:

• Proliferative phase: Rapid growth during first 3-6 months of life
• Plateau phase: Growth slows around 5-12 months
• Involution phase: Begins between 6-12 months
  • 90% of involution is complete by 4 years of age 3
  • Up to 70% leave permanent skin changes (telangiectasia, fibrofatty tissue, redundant skin, etc.) 1

When to Treat

Most hemangiomas (90%) can be managed with observation alone. Indications for active intervention include:

1. Life-threatening complications:

   • Heart failure
   • Respiratory distress
   • Uncontrolled bleeding

2. Functional impairment:

   • Visual obstruction/amblyopia
   • Airway compromise
   • Feeding difficulties

3. Ulceration (painful and risk of scarring)

4. Severe anatomic distortion, especially on the face

5. High-risk locations:

   • Periorbital
   • Airway
   • Liver (multiple lesions)

Treatment Options

First-Line Treatment

Oral propranolol is the treatment of choice for high-risk and complicated IHs 1, 2:

• Dosage: 2-3 mg/kg/day divided into 2-3 doses
• Duration: Minimum of 6 months
• Monitoring: Cardiovascular monitoring may be required when initiating therapy
• Response: Shrinkage is typically observed rapidly after starting treatment

Alternative Treatments

1. Topical timolol 0.5% gel:

   • For superficial hemangiomas
   • When systemic propranolol is contraindicated

2. Corticosteroids:

   • When propranolol is contraindicated
   • Oral prednisolone/prednisone at 2-3 mg/kg/day as morning dose
   • Response rates are variable (30% excellent response, 30% failure, 40% moderate response) 4

3. Surgical interventions:

   • For lesions that fail medical therapy
   • For significant residual tissue after medical treatment
   • For bleeding, ulceration, or functional impairment
   • For cosmetic disfigurement

4. Laser therapy:

   • Often combined with surgery for hemangiomas with skin involvement
   • Particularly useful for residual telangiectasias

Special Considerations for Hepatic Hemangiomas

• Asymptomatic lesions <5 cm: Observation
• Larger or multiple lesions: Surgical options (enucleation or formal liver resection)
• Embolization: Alternative to surgery for lesions ≥5 cm
• Monitor thyroid function as hepatic hemangiomas can deactivate thyroid hormone 1

Follow-up and Monitoring

• Regular follow-up every 3-6 months
• Close monitoring during rapid growth phase (5-7 weeks of age)
• Document changes with photographs when possible
• Educate parents about the natural history and expected outcomes
• Consider prophylactic treatment for high-risk hemangiomas before complications occur

Pitfalls and Caveats

1. Delayed referral: All hemangioma specialists have seen examples of lost opportunities to intervene and prevent poor outcomes due to delayed referral 3

2. False reassurance: Assuming all hemangiomas will resolve without intervention can lead to missed opportunities for treatment during the critical window

3. Misdiagnosis: Congenital hemangiomas and vascular malformations may be confused with IHs but require different management approaches

4. Kasabach-Merritt phenomenon: This consumptive coagulopathy is not associated with typical IHs but rather with other vascular tumors like tufted angiomas 1

5. Permanent changes: Parents should be counseled that even after complete involution, up to 70% of IHs leave permanent skin changes that may require later intervention 3, 1