Initial Approach to Treating Hemangiomas
The initial approach to infantile hemangiomas is observation for uncomplicated lesions, with propranolol as first-line medical therapy reserved for those requiring intervention due to life-threatening complications, functional impairment, pain, bleeding, or risk of permanent disfigurement. 1
Decision Framework: When to Intervene vs. Observe
Observation is Appropriate For:
- Uncomplicated hemangiomas without risk of functional impairment or disfigurement 1
- Small, asymptomatic lesions in non-critical locations 1
- Lesions without high-risk features during the proliferative phase 1
Immediate Intervention is Required For:
Life-Threatening Situations:
- Obstructing hemangiomas of the airway 1
- Hepatic hemangiomas causing high-output congestive heart failure 1
- Severe hypothyroidism from hepatic involvement 1
Urgent Treatment Indications:
- Existing or imminent functional impairment (visual axis obstruction causing deprivation amblyopia, astigmatism, strabismus) 1, 2
- Ulceration with pain and bleeding 1
- Feeding problems from perioral or digestive lesions 1
- Failure to thrive from ulcerated lesions 1
Elective Treatment Considerations:
- High likelihood of permanent disfigurement, particularly with segmental or facial hemangiomas 1
- Lesions in locations where growth may interfere with sight or hearing 3
First-Line Medical Therapy: Propranolol
Propranolol is FDA-approved and represents the standard of care for infantile hemangiomas requiring medical intervention. 1
Initiation Protocol:
- Start propranolol in a clinical setting with cardiovascular monitoring every hour for the first two hours 1
- Repeat monitoring with dosage increases >0.5 mg/kg/day for infants >8 weeks old 1
- Consider inpatient initiation for infants <8 weeks, postconceptual age <48 weeks, or those with cardiac risk factors 1
Alternative Medical Therapy:
Systemic corticosteroids (prednisolone or prednisone 2-3 mg/kg/day as single morning dose) serve as second-line therapy when propranolol cannot be used or is ineffective. 1
- Treatment is most successful when initiated during the proliferative phase 1
- Several months of therapy are typically required 1
- Intralesional steroid injections are effective for small, bulky, well-localized hemangiomas 1
Management of Ulcerative Hemangiomas
Focus on four key elements:
Surgical and Laser Interventions
Laser Therapy Indications:
- Early hemangiomas in favorable locations 1
- Focal lesions where resulting scar would be equivalent to post-involution removal 1
Surgical Resection:
Resection of proliferating infantile hemangiomas is generally not recommended in infancy due to higher surgical risk. 1
- Delay surgery until after infancy to allow for involution and better outcomes 1
- Most hemangiomas do not improve significantly after 4 years of age, making this the optimal timing for correction before self-esteem issues develop 1
Indications for infant resection:
- Failure of other therapies for critical hemangiomas 1
- Diagnostic uncertainty 4
- Compression of adjacent organs 4
Special Populations Requiring Screening
Infants with ≥5 cutaneous infantile hemangiomas require screening for hepatic involvement with abdominal ultrasound, particularly if <9 months of age. 1
- Risk of hepatic hemangioma increases to 8.3% with 5-9 cutaneous lesions vs. 0.4% with <5 lesions 1
- Diffuse hepatic hemangiomas are associated with poor outcomes including mortality 1
Common Pitfalls to Avoid
- Do not assume all hemangiomas will involute without consequence—more than one-third require intervention 1
- Segmental hemangiomas carry higher complication risk than focal lesions 1
- Facial hemangiomas are more complicated than nonfacial lesions 1
- Evaluate for structural anomalies, particularly PHACE or LUMBAR syndrome with certain hemangioma patterns 1, 5
- Early intervention during the proliferative phase (first 6-12 months) may prevent complications and years of psychosocial concerns 1, 5