Hemangiomas - Andre Panossian MD

Hemangioma Treatment in Beverly Hills, CA

Hemangioma (or infantile hemangioma) is a common, well-described vascular anomaly and is present in 1 out of 10 children. Technically, it is a benign vascular tumor of infancy that is usually not present at birth and appears a few days to weeks later. It typically begins as a small red patch or blemish and can rapidly grow to take on its classic appearance. Although most occur in the head and neck region, these tumors or vascular birthmarks can occur virtually anywhere on the body. The life cycle of these birthmarks is very predictable. After their initial presentation, hemangiomas go through a proliferative phase in the first year of life, where they can grow. Eventually, growth stops and the tumor enters a plateau phase. Hemangiomas will then go through a period of involution that may last anywhere between 5 to 10 years until they disappear.

Much confusion surrounds the term “hemangioma.” Many have ascribed this entity to other vascular malformations such as venous malformations which look and behave much differently than true hemangiomas. Some of the words used to describe these birthmarks are “strawberry mark” or “capillary hemangioma.”

IH3-e1300731936878Since most of these marks disappear over time, simple observation is usually all that is required. However, when hemangiomas occur on the face, they can pose a problem for vision, hearing or breathing, not to mention they can be unsightly or disfiguring. They can also ulcerate or bleed profusely. Treatment depends on the extent of the hemangioma and the parents’ wishes. For example, a small hemangioma that is present on the forehead or cheek may be excised. However, larger hemangiomas covering a portion of the face may not be amenable to surgery and may potentially benefit from medical therapy. Medications given by mouth include beta blockers (eg, propranolol or acebutalol) or steroids. Alternatively, problematic portions of large hemangiomas may respond well with one or more injections of steroids every 4 to 6 weeks. Parents frequently ask if lasers may be beneficial. Most hemangiomas are too thick to be treated with lasers. However, there are faint, superficial hemangiomas that may respond well. Also, if caught early, laser treatment may possibly control their growth. Consult Dr. Panossian for an evaluation of your child’s hemangioma for optimal treatment.

Dr. Panossian is an international expert on hemangiomas and other vascular anomalies and has treated hundreds of patients with these lesions. He belongs to the International Society for the Study of Vascular Anomalies, recognized as the preeminent organization for investigating and improving the understanding of all things related to vascular anomalies.

What is a hemangioma?

Hemangiomas are benign blood vessel tumors that occur in childhood.  The most common type of hemangioma is the “infantile” version (referred to sometimes as “strawberry mark”).  Children are not born with these tumors typically. They appear in the first few days to weeks of life as a faint red or pink blemish that can rapidly grow into a larger mass.  Growth will peak at around 12 months of age and plateau thereafter.  It will then take several years for the hemangioma to disappear or involute.  This takes place usually between 3 and 7 years of age. Hemangiomas that are present at birth are called “congenital” hemangiomas.  These do not follow the same life cycle as the infantile kind.  Rapidly-involuting congenital hemangiomas (RICH) will disappear by 12 months of age, whereas non-involuting congenital hemangiomas (NICH) will persist throughout life.

What causes hemangiomas?

There’s currently no known cause for the occurrence of hemangiomas, and it is not hereditary. Approximately 1 in 10 children born will demonstrate some type of hemangioma early in life. It usually occurs in the head and neck region and more prevalently in girls. Children who are twins and/or premature also seem to have a higher tendency for having hemangiomas. Theories suggest that hemangiomas may be derived from the same tissues as placenta. This would seem to fit well with the peculiar life cycle of these tumors, however, there are other differences that still cannot be explained by this theory.

What are options for hemangioma treatment?

Most hemangiomas, being of the “infantile” variant, require no specific intervention. Over time, the hemangioma will initially increase in size, then plateau, and continue on to involution. Often, the entire hemangioma will disappear at the end of this process with no residual signs that it ever was there. Sometimes, hemangiomas may require treatment.  This is true of large hemangiomas, those that cause visible disfigurement, ones that have failed to involute completely, or those that can obstruct vital functions such as vision or breathing.  In these cases, treatment can take the form of medication or surgery.

Currently, medical treatment has taken a big leap forward with the discovery of propranolol for hemangiomas.  Propranolol is a blood pressure lowering medication used all over the world and for many decades in adults.  It is known as a beta-receptor blocker (or, a beta-blocker).  In 2008, it was discovered that children with hemangiomas that were incidentally treated with the medication demonstrated sudden improvement in the appearance of the birthmarks.  Although it will not work in all hemangiomas, there does seem to be an excellent response rate.  It is important to understand that the medication will not necessarily shrink the hemangioma, but it will help stop its growth during the “proliferative” phase within the first year of life.  Thereafter, the hemangioma will continue to involute as it normally does.  The medication can be started as early as one month of age when necessary.  Alternatives to propranolol include oral steroids, steroid injections, or a chemotherapeutic agent (ie, vincristine) for aggressive and resilient types.

Surgery is reserved for hemangiomas that are causing symptoms (eg, ulceration or frequent bleeding) or functional obstruction such as those located over the eyelid or inside the airway. Sometimes, smaller hemangiomas may benefit from early excision to avoid social insecurity during childhood. The decision to pursue a surgical option should be largely guided by the surgeon, who will evaluate whether or not any particular hemangioma can be excised without causing significant secondary deformity.

Is a hemangioma the same as a port wine stain?

There is much misinformation in the world on hemangiomas and vascular birthmarks, in general.  A study by our own practice revealed a rate of misdiagnosis more than 65 percent among patients referred.  Hemangiomas are NOT the same as port wine stains.  Hemangiomas are benign blood vessel tumors that have a fairly predictable life cycle as described above. Port wine stains are capillary malformations that are present at birth and persist throughout life.  The importance of making the correct diagnosis cannot be emphasized enough.  Treatment options are vastly different between these two conditions. Port wine stains are largely treated with pulsed-dye lasers.  Depending on the size of the stain, several treatments over the course of a lifetime are necessary. Some advocate early treatment when the port wine stain is light in order to negate the effects of growth hormones in later years.  Although certain hemangiomas may respond well to similar laser treatments, this is still not effective for large ones.

In addition, there are other considerations with port wine stains. Some of these are associated with overgrowth conditions when located over a limb.  A child may demonstrate a limb length discrepancy as he or she grows.  This is sometimes pronounced during puberty and may require treatment in the form of orthotics, if it significantly affects walking.  In addition, port wine stains occurring over the face need to be scrutinized closely for associated problems, including glaucoma, migraines, and seizures.  The combination of theses symptoms is known as Sturge Weber syndrome.  Although rare, it is important to recognize this condition and have a multidisciplinary team in place to include a plastic surgeon, neurologist, and opthalmologist.





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