Correspondence
Hemangiomas in Children
N Engl J Med 1999; 341:2018-2019December 23, 1999
- Article
To the Editor:
In their otherwise thoughtful and informative article, Drolet and colleagues (July 15 issue)1 dismiss intralesional corticosteroid injection in the treatment of juvenile periocular hemangiomas as “contraindicated, since it is fraught with complications.” I am surprised at this statement, since I believe that intralesional corticosteroids are considered the treatment of choice by a large number of pediatric ophthalmologists and oculoplastic surgeons.2-5
The statement “fraught with complications” is misleading because it implies a high frequency of complications. However, the authors cite only several case reports of complications; no incidence is given. In fact, serious complications occur infrequently with this form of treatment. In tallying my own published and subsequent unpublished cases with the published series of others, I found that no serious complications were observed among a total of more than 200 cases.2,4-6
The authors cited two isolated cases of serious vision-threatening complications after corticosteroid injection into a periocular lesion. However, these complications may have been the result of the dosage, the volume injected, the choice of corticosteroid (its particle size), or the injection technique (the pressure of injection).3,6 For example, in the case they cite of blindness after injection, the patient received more than six times the maximal dosage they recommend. It was the equivalent of giving a 68-kg (150-lb) person approximately 2625 mg of prednisone. In addition, the authors cite a case of eyelid necrosis after intralesional injection, but this has also been reported to occur in untreated patients as a result of spontaneous thrombosis.3
Amblyopia is the main complication of infantile periocular hemangiomas, with an incidence ranging from 43 to 60 percent.3 I am unaware of reports of other treatments that approach the success of intralesional corticosteroids for decreasing the incidence of amblyopia.2,3
6 ReferencesBurton J. Kushner, M.D.
University of Wisconsin, Madison, WI 537051
Drolet BA ,Esterly NB ,Frieden IJ . Hemangiomas in children. N Engl J Med 1999;341:173-181
Full Text | Web of Science | Medline2
Kushner B . Infantile orbital hemangiomas. Int Pediatr 1990;5:249-2573
Haik BG ,Karcioglu ZA ,Gordon RA ,Pechous BP . Capillary hemangioma (infantile periocular hemangioma). Surv Ophthalmol 1994;38:399-426
CrossRef | Web of Science | Medline4
Sloan GM ,Reinisch JF ,Nichter LS ,Saber WL ,Lew K ,Morwood DT . Intralesional corticosteroid therapy for infantile hemangiomas. Plast Reconstr Surg 1989;83:459-467
CrossRef | Web of Science | Medline5
Boyd MJ ,Collin JR . Capillary haemangiomas: an approach to their management. Br J Ophthalmol 1990;75:298-300
CrossRef | Web of Science6
Kushner BJ ,Lemke BN . Bilateral retinal embolization associated with intralesional corticosteroid injection for capillary hemangioma of infancy. J Pediatr Ophthalmol Strabismus 1993;30:397-399
Web of Science | Medline
To the Editor:
In their review article, Drolet and colleagues focus on giant and life-threatening hemangiomas in children. However, giant hemangiomas are rare; small-to-medium capillary or cavernous hemangiomas represent the overwhelming majority of these lesions. The lesions may be present at birth or develop within the first months of life, initially presenting as red spots, macules, or flat patches. Treatment with the flashlamp-pumped pulsed dye laser is first-line therapy to prevent further enlargement and to induce complete remission of strawberry marks at that early stage, without scarring. In our own study of 100 capillary hemangiomas, there was a response to laser treatment in 92 percent of the lesions (complete remission in 23 percent, partial remission in 55 percent, and arrest of growth in 14 percent).1 All the hemangiomas that were treated at an early stage disappeared completely after the first course of laser treatment.
Although the flashlamp-pumped pulsed dye laser was introduced in the late 1980s for the treatment of vascular malformations, pediatricians and obstetricians appear to be reluctant to refer patients for early treatment. Unfortunately, a majority of infants are admitted too late, when strawberry marks have already developed to their definitive size.2 Laser therapy of full-grown lesions is much more cumbersome than early therapy and appears to have no advantage over other types of treatment.
2 ReferencesHarald Maier, M.D.
Reinhard Neumann, M.D.
University of Vienna Medical School, A-1090 Vienna, Austria1
Maier H ,Neumann R . Treatment of strawberry marks with flashlamp-pumped pulsed dye laser in infancy. Lancet 1996;347:131-132
CrossRef | Web of Science | Medline2
Glassberg E ,Lask G ,Rabinowitz LG ,Tunnessen WW Jr . Capillary hemangiomas: case study of a novel laser treatment and a review of therapeutic options. J Dermatol Surg Oncol 1989;15:1214-1223
Medline
Author/Editor Response
The authors reply:
To the Editor: We agree with Kushner that our statements regarding intralesional injection of corticosteroids in the periocular area should be modified. This form of treatment is frequently used by ophthalmologists for the treatment of periocular hemangiomas. However, several adverse effects have been reported, and there are no data on the incidence of these complications. The most frightening of these complications — occlusion of the central retinal artery with resulting contralateral blindness — occurred in one of our patients, a circumstance that undoubtedly influenced our recommendations. The risk of retinal-artery occlusion may increase in patients given higher concentrations of corticosteroids, in patients with anomalous arterial circulation, such as infants with very extensive facial hemangiomas, and in patients with hemangiomas that extend into the retrobulbar space.1 The risk of these rare complications must be weighed against the possibility of loss of vision due to amblyopia from the hemangioma, as well as the potential risks associated with alternative approaches such as surgery and systemic corticosteroids.
In response to Maier and Neumann's comments, we agree that the majority of hemangiomas are small and not life-threatening. Although hemangiomas occur most commonly in the head and neck, many occur in sites of much less cosmetic concern and do not require any intervention. Hemangiomas on exposed areas do provoke attention and are understandably distressing to parents. Our own experience and most published articles indicate that very superficial hemangiomas can be effectively treated with the flashlamp-pumped pulsed dye laser, but that thicker hemangiomas and those with an important subcutaneous component do not respond because of the limited penetration of this treatment.2,3 Moreover, the deeper dermal or subcutaneous component of the hemangioma may continue to develop, despite early laser treatment.4
Unfortunately, there have been no well-designed studies that compare the efficacy of laser treatment with that of other therapies or no treatment. Given the unpredictable nature of hemangiomas, it is difficult to interpret data from relatively small, uncontrolled studies. We agree that consideration of the flashlamp-pumped pulsed dye laser for superficial hemangiomas in a cosmetically sensitive area is reasonable, but the results are somewhat unpredictable, probably because of the inherent growth characteristics of hemangiomas. Moreover, the risk of scarring appears to be somewhat higher than the risk when treating infants with port-wine stains (unpublished data). Finally, this treatment is relatively ineffective for rapidly growing, more aggressive, so-called alarming hemangiomas, which have the greatest potential for causing functional impairment or permanent disfigurement. Use of the flashlamp-pumped pulsed dye laser in this situation can be potentially harmful if it delays the use of more biologically active therapy, such as corticosteroids.
4 ReferencesBeth A. Drolet, M.D.
Nancy B. Esterly, M.D.
Medical College of Wisconsin, Milwaukee, WI 53226Ilona J. Frieden, M.D.
University of California at San Francisco, San Francisco, CA 941151
Frieden IJ ,Reese V ,Cohen D . PHACE syndrome: the association of posterior fossa brain malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. Arch Dermatol 1996;132:307-311
CrossRef | Web of Science | Medline2
Barlow RJ ,Walker NP ,Markey AC . Treatment of proliferative haemangiomas with the 585 nm pulsed dye laser. Br J Dermatol 1996;134:700-704
CrossRef | Web of Science | Medline3
Scheepers JH ,Quaba AA . Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years' experience. Plast Reconstr Surg 1995;95:305-312
CrossRef | Web of Science | Medline4
Ashinoff R ,Geronemus RG . Failure of the flashlamp-pumped pulsed dye laser to prevent progression of deep hemangioma. Pediatr Dermatol 1993;10:77-80
CrossRef | Web of Science | Medline
- Citing Articles (5)
Citing Articles
1
Daniel O. Beck, Arun K. Gosain. (2009) The Presentation and Management of Hemangiomas. Plastic and Reconstructive Surgery 123:6, 181e-191e
CrossRef2
R Friling, R Axer-Siegel, D Ben-Amitai, N Goldenberg-Cohen, D Weinberger, M Snir. (2009) Intralesional and sub-Tenon's infusion of corticosteroids for treatment of refractory periorbital and orbital capillary haemangioma. Eye 23:6, 1302-1307
CrossRef3
M. Momtchilova, B. Pelosse, P.-A. Diner, M.-P. Vazquez, L. Laroche. (2004) Amblyopie et hémangiome orbito-palpébral capillaire chez le jeune enfant : dépistage et évolution pré et post-chirurgicale. Journal Français d'Ophtalmologie 27:10, 1135-1140
CrossRef4
Michael O'Keefe, Bernadette Lanigan, Sinead A. Byrne. (2003) Capillary haemangioma of the eyelids and orbit: a clinical review of the safety and efficacy of intralesional steroid. Acta Ophthalmologica Scandinavica 81:3, 294-298
CrossRef5
Scott M. Dinehart, Jay Kincannon, Roy Geronemus. (2001) Hemangiomas: Evaluation and Treatment. Dermatologic Surgery 27:5, 475-485
CrossRef
