early treatment of infantile haemangiomas
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Treatment of infantile haemangiomas
Who, when, why and how
Diana PurvisPaediatric Dermatologist
Starship Children’s Hospital
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Conflicts of interest
• Galderma: sponsored meeting attendence, education scholarship and honoraria
• Nutricia: sponsored meeting attendence and honoraria
• Pierre-Fabre: sponsored research
• Johnson and Johnson: medical advisor
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Classification of vascular anomalies(ISSVA)
• Vascular tumours
– Benign
• Infantile haemangioma
• Congenital haemangioma
– RICH, NICH, PICH
• Tufted angioma…
– Borderline
• Kaposiform
haemangioendothelioma
• Kaposi sarcoma…
– Malignant
• Angiosarcoma…
• Vascular malformations– Simple
• Capillary malformation (PWS)
• Venous malformation
• Lymphatic malformation
• Arterial malformation
– Combined• AVF, AVM, CVM, CLVM, LVM,
CAVM, CLAVM
– Associated with other anomalies
• Sturge Weber, Klippel Trenaunay, Parkes Weber, Proteus, CLOVES…
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Infantile haemangioma
• Benign vascular tumors
• Affect 2-5% of infants
• Not present at the time of birth
• Characterised by rapid postnatal growth
– 80% growth occurs by 3 months of age
• Followed by spontaneous regression
– Most regression occurs by 3.5 years of age
• Approximately 10% may cause complications
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Complications of infantile haemangiomas
• Obstruction of vision/airway
• Ulceration
• Pressure effects on cartilage
• Stretching of soft tissues
• Telangectasia
• Fibrofatty tissue residua
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PHACES syndrome
• Posterior fossa brain abnormalities
• Segmental Haemangiomaof the head/neck
• Arterial abnormalities
• Coarctation of aorta
• Eye abnormalities
• Sternum abnormalities
• Present in 31% of infants with a segmental IH of the head/neck >22cm
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Haemangiomatosis
• >5 infantile haemangiomas
• May be disseminated egintrahepatic, intracranial
• Risk of cardiac failure, hyperthyroidism
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Propranolol for infantile haemangiomas
• Leaute-Lebreze et al
• Pediatrics 2008
• Propranolol 2mg/kg/day
• Supported by case series and RCT
• More effective than corticosteroids
• Atenolol, nadolol, topical timolol also seem effective
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2 months
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6 monthsWithout treatment
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• 6 months
6 monthsWith propranolol
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• 8 months
9 months
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11 months
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Propranolol – unwanted effects
• Bradycardia and hypotension– Maximal 1-3 hours post-dose
• Hypoglycaemia– Unpredictable – routine screening not advised– Advise discontinue with intercurrent illness or reduced oral
intake
• Cool peripheries• Altered sleep• Neurodevelopment to 5 years normal
• Initiation in paediatric daystay or hospital setting– Cardiovascular examination, BP, +/- ECG
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When to treat haemangiomas
• Airway compromise– Subglottic, nasal, intraoral
• Visual axis– Intraorbital, eyelid
• Ulcerated– Perineal, lip, segmental, flexural
• Risk of permanent significant cosmetic defect– Nasal tip, lip, ear, face, etc
• Haemangiomatosis– Disseminated lesions – intrahepatic, intracranial…
• Treatment is most effective if commenced before 8 weeks of age
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When to refer infantile haemangiomas
• When you think beta blockers may be indicated– in the airway or affecting visual axis
– ulcerated
– on the face/anterior neck
– in the nappy area
• When investigation may be needed– Segmental haemangioma
– Multiple >5 haemangiomas
• When there is doubt about the diagnosis– Present on the day of birth
– Onset after first weeks of life
– Atypical appearance or growth trajectory
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Diana PurvisDermatologist
Starship Children’s Hospital
81 Remuera Road
Newmarket
Ph 09 5244333
Fax 09 5242106
Tuesday & Thursday
17 Gilgit Road
Epsom
Ph 09 6310088
Fax 09 6300323
Friday