Best treatment option for infantile hemangioma 2024

Treating infantile hemangioma through various methods.

Infantile hemangiomas (IHs) are proliferative, benign vascular tumours of the vascular endothelium that can appear before birth or, more frequently, in the first two weeks of life. They expand predictably and then spontaneously involute.

IHs are the most typical infant tumour, affecting 5% of all infants.

The normal course of treatment for an IH consists of expectant surveillance in patients who do not have any significant side effects or excessive growth that might cause tissue damage and severe deformity. Therapy is rarely necessary because almost all lesions resolve spontaneously.

Parents need encouragement and reinforcement repeatedly. Many individuals experience minor cosmetic flaws following spontaneous involution, including telangiectasia, hypopigmentation, fibrofatty deposits, and scars if the lesion has ulcerated.

Pulsed-dye laser therapy can be used to treat telangiectasias that are still present. If needed, prudent surgical correction can be used to treat or minimise other flaws.

Timolol solution (0.5% gel; maximum dose 0.5 mg/day) is beneficial when intervention is necessary, especially in minor, superficial, nonulcerating, and nonmucosal IH.

Currently, observation alone for a superficial IH appears to be a highly safe alternative to topical timolol treatment. When treating an IH ulcer with or without occlusion, timolol solution may also be administered with caution.

Oral propranolol is typically the first-line treatment for IH that is disfiguring, life- or vision-threatening, or ulcerated and not responding to other therapies. Within a few weeks of starting treatment, IHs normally respond with growth stop and frequently with early symptoms of involution.

INPATIENT TREATMENT STRATEGIES
The dosage can range from 1-3 mg/kg/day. For newborns under 8 weeks of gestation or those with concomitant illnesses, some advise starting propranolol as an inpatient. Heart rate and blood pressure are monitored at 1 and 2 hours after each dose as the dose is started at 1 mg/kg/day divided into 3 doses. The dose is increased to 2 mg/kg/day tid if the first dose is tolerated.

OUTPATIENT TREATMENT STRATEGIES
The outpatient start-up presupposes excellent social support and hospital accessibility. If the dose is tolerated for 3–7 days, it is increased to 1.5 mg/kg/day tid. The initial dose and monitoring are similar to the inpatient protocol. After 3–7 days, if the second dose is still well tolerated, the dosage is increased to 2 mg/kg/day tid. Propranolol must always be administered at least 6 hours following the last dose in all circumstances.

SIDE EFFECTS OF PROPRANOLOL
Hypoglycemia, bradycardia, hypotension, gastroesophageal reflux disease (GERD) or exacerbation of pre-existing disease, hyperkalemia, and bronchospasm are risks associated with the use of propranolol. Though uncommon, reports of propranolol side effects when used to treat IH do exist.

DRUGS INTERACTION
Cimetidine, amiodarone, fluoxetine, quinidine, ritonavir, and theophylline are CYP2D6 and CPY1A2 inhibitors, respectively, while rifampin, phenytoin, and phenobarbital are inducers of hepatic drug metabolism, which result in decreased blood levels of propranolol.

Systemic oral corticosteroids may be utilised in patients who are unable to tolerate propranolol or if the IH has not improved after a few weeks of treatment. After 2-4 weeks of therapy, growth may stop and, in rare cases, regression may be visible. The dose should be gradually reduced after a response is seen, though the majority of patients will need treatment for roughly 1 year of age.

INTERALESIONAL CORTICOSTERIOD
Injection of intralesional corticosteroids can hasten the involution of a localised IH in the hands of a skilled medical professional, but if administered close to the orbit, there is a risk of ulceration, tissue atrophy, and blindness.

Oncologists sometimes treat substantial IH with vincristine.
There is a 10% chance of spastic diplegia with interferon therapy, but it may still be helpful.
Since propranolol was introduced, use of these treatments has become less necessary.

PHACE syndrome should be taken into consideration in patients with severe segmental IH of the face.

The acronym PHACE stands for posterior fossa brain defects, including Dandy-Walker malformation and cerebellar hypoplasia, massive segmental facial infantile hemangiomas, arterial cerebrovascular abnormalities, including aneurysms and stroke, coarctation of the aorta, and eye abnormalities. It is uncommon to see sternal raphe deformities such pits, scars, or supraumbilical raphe.

When a child is at risk for developing PHACE, it’s crucial to have them evaluated to rule out any underlying abnormalities and to determine whether systemic therapy is necessary given the size and location of the IH that is frequently linked to this syndrome. Cerebrovascular accidents are more likely to occur in PHACE children with cervical and intracranial artery anomalies, hence specialised care from a skilled multidisciplinary team is crucial.

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Q-Should you treat infantile hemangioma