Clinical course has been described as having 6 stages (Chang, Pediatrics, 2008).
- Immediately after birth
- Prior to emergence of visible lesion
- Usually 0–3 months
Early and late proliferative stages
- Rapid growth in early proliferative stage
- Less rapid growth in late proliferative stage
- Usually 6–10 months
- 80% of lesions reach maximum size by 5 months.
- Most lesions stop growing by 9 months.
- Deep and segmental lesions can have longer proliferative phase.
(Margileth, JAMA, 1965)
- About 50% of lesions regress by age 4.
- About 75% regress by age 7.
Good option for small lesions that are not causing
- Visual impairment
- Occlusive or astigmatic amblyopia
- Exposure keratopathy
- Compressive optic neuropathy
- Skin ulceration
Systemic beta blockers
- Currently the preferred intervention when large lesions require treatment
- Can work via vasoconstriction through nitrous oxide release, inhibition of VEFG and bFGF and apoptosis of proliferating endothelial cells (Storch, Br J Dermatol, 2010)
- Multiple case reports and case series have demonstrated good response.
- Case series of 17 patients: decrease in size in 100% (Haider, J AAPOS, 2010)
- Case series of 18 patients: similar findings (Missoi, Arch Ophthalmol, 2011)
- One Randomized, double-blind, controlled trial (Hogeling, Pediatrics, 2011)
- Was not specific to periocular lesions
- Stopped lesion progression in all patients by 4 weeks (versus 16 weeks for placebo group)
- Decrease in volume of lesion in propanolol group at all time points
- Side effects (Siegfried, N Engl J Med, 2008)
- Blunted hypoglycemic response
- Congestive heart failure
- Sleep disturbance
- Careful pretreatment history and monitoring during treatment are required.
- Patients/guardians should be informed of off-label use of medication.
Intralesional beta blockers
One prospective, nonrandomized study of 10 patients receiving intralesional triamcinolone 40 mg/ml and 12 patients receiving intralesional propanolol 1 mg/ml (Awadein, Clin Ophthalmol, 2011) reported a similar response.
- 40% "excellent" response
- 40%–45% "fair" response
- 17%–20% no response
Topical beta blockers
- Timolol 0.5%, which daily showed good response in 7 patients (Ni, Arch Ophthalmol, 2011)
- Reduction in size of 55%–95% in 4–8 weeks
- 73 patients with infantile hemangioma anywhere on skin treated with gel forming timolol maleate 0.1% or 0.5% twice daily (Chakkittakandiyil, Pediatr Dermatol, 2012)
- Good response with minimal side effects
- Potential treatment option for patients with superficial lesions
Systemic steroids at 2–5 mg/kg/day have been shown to be effective (Zak, J Pediatr Ophthalmol Strabismus, 1981).
Prednisone at 20 mg daily for 3–8 weeks showed favorable response in 84% after 2 months (Bennett, Arch Dermatol, 2001).
- Some patients required up to 6 months.
- 35% rate of side effects
- Behavioral changes
- Cushingoid appearance
- Growth retardation
(Kushner, Plast Reconstr Surg, 1985)
- Intralesional injection of 1–2 ml of 1:1 mixture of Betamethasone 6 mg/ml and triamcinolone 40 mg/ml
- Can see rapid improvement (within days)
- Infrequent but serious potential side effects
- Ophthalmic artery embolus
- Skin or fat atrophy or skin necrosis
Figure 1. Four-month old infant with left upper eyelid hemangioma causing occlusion of the visual axis.
Figure 2. One month after intralesional corticosteroid injection has resulted in significant reduction in hemangioma size and now allows elevation of the upper eyelid.
(Garzon, J Am Acad Dermatol, 2005)
- Clobetasol propionate, 0.05%, halobetasol propionate 0.05%, or betamethasone dipropionate used once or twice daily
- 33% with improvement, 33% with partial improvement, and 33% without improvement
- Potentially useful for superficial lesions
- Fewer side effects
- Glaucoma or cataract formation
(Callahan, Saudi J Ophthalmol, 2012)
Argon laser, Nd-YAG laser, carbon dioxide laser, fractional photothermolysis and pulsed dye laser have been tried.
Pulsed dye laser is best studied and most widely used.
- Uses light of the same wavelength as the infantile hemangioma blood vessels
- Can be helpful for superficial lesions
- Penetration of 1.2 mm
- Required multiple passes, with 8 or more sessions every 1–2 months
- In one study of 617 patients, stopped growth in 97%, resolved lesions in 14%, and caused partial resolution in 15% (Hohenleutner, Lasers Surg Med, 2001)
- Side effects (Bennett, Arch Dermatol, 2001)
- Hyperpigmentation and atrophic scarring
- Primarily halt progression rather than cause regression of lesions
- Might have a role in select lesions, e.g., lesions causing skin ulceration
- Usually reserved for patients who have not responded to nonsurgical treatment
- Side effects
- Bleeding risk
- Can use various techniques including preemptive ligation and cauterization of vessels prior to excision to minimize blood loss
Figure 3. Fifteen-month old child with residual hemangioma of the left upper eyelid resulting in a persistent chin-up head positioning despite treatment with oral propranolol and intralesional corticosteroid injections.
Figure 4. Two weeks after surgical debulking and excision of the left upper eyelid hemangioma.