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Treatment Options

Hemangiomas

The first thing you should realize is that there are options for treatment. There is no reason in this day and age to accept that the only option available is to ‘leave it alone’ and wait for the hemangioma to ‘go away’. Secondly, the most appropriate treatment plan needs to be individualized for each patient and each lesion. Therefore, similar lesions in different patients may be treated differently. Likewise, a given child may have more than one hemangioma and each of those may be treated differently. There are various factors that come into play when deciding what treatment is best – whether the hemangioma is proliferating or involuting; whether it is superficial, deep or compound; the location of the lesion and the age of the child. In general, there are four potential treatment options which may be used singly or in combination.

Observation – we include this as a treatment option because sometimes it is very appropriate to see what happens. This is very different than ‘leave it alone it will go away’. It is a conscious decision to wait for a pre-determined period of time to see what the birthmark is doing. For example, we may have a 1 month old infant who recently developed a deep hemangioma of the upper back. Because it is so early we don’t know how much this lesion may proliferate. It would be very appropriate to watch it for a couple of months to see what happens. This would give the baby a chance to grow and gain weight. If after a couple of months not much had happened or the hemangioma were proliferating slowly we may choose to wait another couple of months. On the other hand, were things to dramatically start to change, the baby could be seen earlier and other options considered. So, observation is an active process not passive neglect.

Steroids – these powerful medicines are the mainstay of medical treatment for hemangiomas. Their goal is to slow down the growth of the lesion. So, they are only useful during proliferation – treating an involuting hemangioma with steroids is no useful though it is, unfortunately, commonly done. Oral or systemic steroids are used for rapidly proliferating lesions in a cosmetically sensitive area or one causing functional impairment. The rare lesions that are life-threatening are always treated with steroids and, occasionally, other medicines. There are several side effects to these medicines so their use needs to be carefully monitored. However, they are very effective in slowing down the proliferation and buying time for other options. There is evidence that shows that systemic steroids used for the treatment of problematic hemangiomas have short term side effects but no long term complications. When these drugs are used, they must be used at a high enough dose for a long enough period of time and the child must be monitored by a specialist and a pediatrician. The steroids must be carefully weaned off and sometimes they need to be restarted at a lower dose because the hemangioma ‘rebounds’ or begins to grow again. The closer we get to 12 months of age, the less likely the lesion is to continue growing. Intra-lesional injections of steroids, in our opinion, are of benefit in a limited number of cases. The typical lesion which will respond to steroid injections is small, circumscribed and deep. Traditionally, lesions around the eye have been treated with these injections though, in our opinion, surgery is often a better option. In any case, the injections must be repeated several times to see an effect.

Lasers – there are many types of lasers which do many different types of things. The goal of laser treatments is to effect complete removal of a lesion, set the stage for further treatments, treat complications or treat the inevitable broken blood vessels (telangiectasias) left behind as a hemangioma involutes. The pulsed dye laser (PDL) with a dynamic cooling device is the mainstay for treatment of the superficial vascular component of the hemangioma. It can be used to slow the proliferation; reduce the redness and set the stage for other treatments. Multiple treatments are typically needed. Depending on the lesion, the age of the child and the location the treatments may be done with or without anesthesia. The least traumatic and safest way is chosen for each patient. The PDL can be used to help heal hemangiomas that have ulcerated (the skin has broken open). This is particularly helpful for lesions in the diaper area. The Nd:YAG laser is used for treating the deep component of hemangiomas involving the oral cavity, larynx (voice box) and, occasionally, the skin. This laser must be very carefully used by experienced physicians. The KTP laser is most commonly used for airway lesions too. Resurfacing lasers such as the CO2 and Erbium are used to help with scar revisions and improving the texture of the skin after involution. In children, these must be used very carefully as well.

Surgery – this, along with lasers, is the option that has changed the results we can obtain most dramatically. There are a lot of misconceptions about operating on hemangiomas – the risk of hemorrhage in particular – that we are trying to educate physicians about. Unfortunately, there are some physicians who on TV and in lectures scare families into thinking that only a handful of surgeons are capable of doing these surgeries. The reality is that the reason there aren’t that many of us doing this kind of work is because doctors haven’t yet learned. This Foundation is committed to training other doctors to successfully operate on these lesions so families don’t have to travel such great distances for treatment. In general, children can be operated on very successfully with a minimal amount of blood loss.

The goal of surgery is to remove the lesion completely; set the stage for other treatments; or correct what is left after involution. We can operate on lesions throughout proliferation or involution. The exact timing is influenced by the child’s age and weight as well as the impact the hemangioma is having on function. For example, a rapidly proliferating compound hemangioma of the upper eyelid that is beginning to impair vision may be removed at an earlier point than a deep hemangioma of the back which has begun to involute. Surgeries may be done in stages in certain cases in order to get the best cosmetic result. Scar revisions, in particular, need to be done judiciously in young patients.

The combination of all the above modalities is very commonly used. We may treat the superficial component of a compound hemangioma of the nasal tip with the PDL in preparation for surgery of the deep component. Or we may treat a deep hemangioma of the orbit that is pushing on the eyeball with steroids at the same time we use the PDL for a separate superficial lesion in the same patient. The bottom line is there are options.

Vascular Malformations

Many of the same modalities that are used for hemangiomas are used in the treatment of malformations. There are some important differences however. Malformations are true developmental abnormalities of the involved structures. So, any part of the malformation that is left behind after treatment has the potential for growing. This, of course, is not the case with hemangiomas. It is very important that the goals of the treatment are clearly established. Sometimes it is not possible to remove the entire malformation surgically without causing harm to normal structures so a more conservative approach may be chosen knowing that multiple treatments may be necessary or that another treatment tool, such as embolization or sclerotherapy, may be needed. Embolization and sclerotherapy are procedures done by an Interventional Radiologist and are useful to close down the blood supply of a malformation (venous or arterio-venous malformations, for example) prior to surgery or as the primary treatment option. Special medicines can be used as well as different coils, sponges and other materials. The purpose of these treatments may also be to scar down the malformation (such as with lymphatic malformations). The interventional radiologist is also very helpful in doing studies prior to surgery to help map out the malformation. The most common malformation for which lasers are used is the port wine stain. For these, the pulsed dye laser (PDL) with a dynamic cooling device is the currently the best treatment. Early treatment of port wine stains is advocated to try to close off the abnormal vessels. Even after this malformation clears, touch up treatments may be needed in the future. Remember, any vessel that is left behind has the potential for growing. There is no current way to completely get rid of a port wine stain permanently. However, it is definitely worth treating in order to avoid complications such as ‘peppercorns’ or ‘cobblestones’. Once these areas of thickening occur they are more difficult to treat. The Nd:YAG and resurfacing lasers are useful in these instances as well. Likewise, we try to prevent the overgrowth of tissues by using the laser early on. Surgery is useful for port wine stains to reduce the size of structures that have thickened such as the lips, eyelids and nose.

Steroids are typically used only occasionally in the treatment of malformations to reduce swelling during flare-ups. For example, lymphatic malformations can enlarge during a viral illness or venous malformations may get ‘clogged’ with calcifications causing pain and swelling – steroids may be used as a temporary measure to treat these problems. However, unlike with hemangiomas, the steroids are not treating the malformation itself.

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