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Treating Ulcerated Infantile Hemangiomas

Hemangioma is the most common tumor to affect infants, and ulceration is one of the most frequent complications. Despite the prevalence of this problem, its epidemiology is not well documented, its pathogenesis remains unexplored, and a uniform approach to therapy has not been defined. This paucity of clinical investigation inspired these authors to conduct a retrospective analysis of 60 patients with ulcerated hemangiomas seen over a 10-year period by a pediatric dermatologist at the University of California, San Francisco.

Ulceration was present upon initial evaluation in 90 percent of cases and developed thereafter in the rest. Most lesions were plaque-type, larger than 6 cm², and located on the head and neck. One-third involved the perineum. Onset of ulceration ranged from birth to 13 months, with a mean age of 3 months. Only 5 percent developed ulceration after 10 months of age. Three infants (5 percent) experienced severe bleeding. Six (10 percent) had evidence of S. aureus superinfection, but more than 4 times as many were empirically treated with systemic antibiotics. Other therapies used were topical antibiotics (metronidazole gel [35 percent], mupirocin ointment [32 percent]); dressings (Vaseline gauze [23 percent], DuoDERM Extra Thin [18 percent]); corticosteroids (intralesional [12 percent], systemic [37 percent]); interferon (7 percent); and surgery (3 percent). Most patients received multiple concurrent treatments. Approaches to management evolved in the 10 years covered by the review. Pulsed-dye laser was introduced 3 years into the period and used in 22 patients (37 percent), 11 of whom (50 percent) improved. Mean ulcer duration was 86 days.

Comment: These findings refute the popular belief that ulceration marks the beginning of hemangioma involution. The study also documents the rare incidence of severe bleeding, an often-feared but rare complication of infantile hemangiomas that occurs in very few ulcerated lesions. Any conclusions drawn from these results should reflect the preponderance of difficult cases in this group of tertiary referral patients; ulcer duration and the importance of hemangioma size may be over-represented. The treatment courses reflect an unavoidable trial-and-error approach. Notable findings are the lack of response to pulsed-dye laser in 4 of 14 patients with ulcerated hemangiomas of the perineum (29 percent) and worsening in 1 of 2 patients with lip lesions. Further analysis of this challenging problem is clearly warranted.

— EC Siegfried

Published in Journal Watch Dermatology September 11, 2001

Citation(s):

Kim HJ et al. Ulcerated hemangiomas: Clinical characteristics and response to therapy. J Am Acad Dermatol 2001 Jun 44 962-972.

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