Skin hemangioma treatments - Hemangioma removal

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Early removal of skin hemangioma with combination or multiple treatment options helps in reducing the risks of scars, cosmetic blemishes, facial disfigurement and other serious complications.

There are many treatment options available for removal of hemangioma on skin. Depending upon the need, individualized treatment plans can be opted for each patient as well as each lesion.

Medical observation and evaluation of hemangioma

     There is a drastic change from the traditional approach to hemangioma relief, like ‘leave it alone it will go away’, to having a close medical observation, frequent evaluation of the lesions and early intervention and removal, if necessary, to avoid future complications, life-risks and cosmetic skin disfigurements.

     Only about 2% of infantile skin hemangiomas are actually visible at birth. Tollefson M.M and Frieden I.J in their study "Early growth of infantile hemangiomas: what parents' photographs tell us." concluded that the precursors were present at birth in 65% of patients. They found that IH growth was nonlinear; most rapid growth occurred between 5.5 and 7.5 weeks of age and that the most rapid hemangioma growth occurred before 8 weeks of age. Megha M. Tollefson and colleagues found that the mean "optimal age for referral" was 4 weeks of age.

     They suggest "a need for a paradigm shift in the timing of referral and initiation of treatment of high-risk IH so that therapy can be initiated before or early in the course of most rapid growth, rather than after it is already completed".

Hemangioma treatment and removal with medications

     Steriods are the first-line medications for the treatment and removal of skin hemangiomas. As oral systemic corticosteroids slow down or stop the growth of lesions, they are successfully used for treatment and removal of rapidly proliferating lesions. By blocking the rapid proliferation phase, the involution phase may get advanced. This helps in buying time for taking up other treatment and removal strategies.

     Some infants may develop side effects for steroids like immunosuppression, gastrointestinal upset or retarded growth and hence close monitoring is necessary during the healing.

     Intra-lesional injections of corticosteroids into localized, small or deep skin hemangiomas in problematic areas like eye lids and ear canals have been found to be useful. Topical corticosteroids are useful in removal of small superficial strawberry birthmarks on skin.

     Propranolol, a sympatholytic non-selective beta blocker, has been used for many years in treatment of hypertension, anxiety and panic. In recent studies it was found that propranolol can be used for treatment of severe infantile hemangiomas. Further controlled trials have to be conducted for proving its efficacy for therapetic use. Many adverse drug reactions (ADRs) like  nausea, diarrhea, bronchospasm, hypotension, heart failure and dizziness are associated with the use of propranolol.

     Vincristine, a mitotic inhibitor used in cancer chemotherapy, has been successfully used for treatment and removal of lesions, which are problematic and are affecting vital functions. Vincristine is delivered via intravenous infusion. As vincristine has main side-effects like peripheral neuropathy, hyponatremia, ascending paralysis, and spinal nerve demyelination, it has to used with great caution.

     Interferon-alpha injections have been used successfully for treatment and removal of lesions affecting vital functions. Interferon-alpha also has many  adverse effects like flu-like symptoms, neutropenia, immunosuppression and convulsions.

Treatment and removal with surgical excision

     Hemangioma lesions are operable both during proliferation and involution phases. However the removal of proliferating skin hemangiomas by surgical excision is potentially risky due to possibility of hemorrhage and damage to vital tissues. This procedure has to be performed only by well trained surgeons. This type of early intervention and removal can preserve vital functions and reduce the psychosocial impacts associated with cosmetic disfigurement during childhood.

     Surgical excision and removal of loose skin or dilated bundles of blood vessels remaining after the involution of hemangioma is recommended to improve the esthetic appearance of the child. Generally lesions which regress slowly are likely to leave atrophic and hypertrophic scars, thinning of the skin or structural irregularities of the skin. Removal of these skin blemishes may require corrective surgery.

Skin hemangioma treatment and removal with lasers

     Among the various laser treatments available pulsed dye laser (PDL) with a dynamic cooling device is the first-line laser treatment for removal of these superficial skin lesions. Pulsed dye laser is very helpful in case of ulcerated skin lesions and telangiectasia (broken blood vessels) after regression.
   
     For removal of lesions involving deep hemangiomas of oral cavity, larynx, pharynx or airway, Nd:YAG laser can be used. Nd:YAG (neodymium-doped yttrium aluminum garnet; Nd:Y₃A_l5O₁₂) is a crystal that is used as an active laser medium for solid-state lasers. Potassium titanyl phosphate (KTiOPO₄) or KTP laser and carbon dioxide lasers are used for treatment and removal of airway hemangiomas.

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References:
1. Tollefson MM, Frieden IJ. Early growth of infantile hemangiomas: what parents' photographs tell us. Pediatrics. 2012 Aug;130(2):e314-20. Epub 2012 Jul 23.
2. Haggstrom AN et al. (September 2006). Pediatrics 118 (3): 882–7. doi:10.1542/peds.2006-0413. PMID 16950977. "Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment".