Video Abstracts -- brief videos summarizing key findings of new articlesDiagnosis and Management of Infantile Hemangioma
Article Figures & Data
Figures
- FIGURE 1
RICH is fully formed at birth (A) and then involutes, mostly during the first year of life. B, The same lesion seen at 8 months of age.
- FIGURE 2
Pyogenic granulomas have some clinical and histologic features similar to IHs, but they are generally smaller, pedunculated, and more likely to bleed.
- FIGURE 3
A, The venous blood contained within a venous malformation imparts a bluish hue that may lead to misdiagnosis as a deep IH. B, Bleeding into surface vesicles of a lymphatic malformation may lead to misdiagnosis as an IH.
- FIGURE 4
Proliferative phase IH. Well-circumscribed lobules of closely packed capillaries composed of plump endothelial cells and pericytes are separated by normal-appearing dermal stromal elements (hematoxylin and eosin stain; original magnification ×100; photo courtesy of Paula North, MD.)
- FIGURE 5
Involutive phase IH. Lesional capillaries are set within loose fibro-adipose tissue and are less densely packed than in the proliferative phase. Note the thickened and hyalinized basement membranes studded with apoptotic debris, reflective of the involutive process. Residual lining endothelial cells are mitotically inactive. (Photo courtesy of Paula North, MD)
- FIGURE 6
Cutaneous IHs may be classified on the basis of their depth. A, Superficial IHs are visible only at the skin surface and may be focal (as shown) or segmental. B, Deep IHs have no surface involvement. C, Mixed, or compound, IHs have both superficial and deep components.
- FIGURE 7
Abortive IHs are macular, telangiectatic patches that have failed to fully proliferate.
- FIGURE 8
(A) Patterns of segmental IH of the face extracted from image analysisdefined. Seg1 (frontotemporal), Seg2 (maxillary), Seg3 (mandibular), and Seg4 (frontonasal). (B) An ulcerated segmental IH in the maxillary distribution.
- FIGURE 9
Multifocal cutaneous IHs in a child with IH of the liver.
- FIGURE 10
Ulcerated segmental IH of the perineal/perianal region.
- FIGURE 11
A, The presence of multiple IHs in the “beard” distribution is associated with a higher likelihood of airway involvement (reproduced with permission from J Pediatr. 1997;131(4):643–646 ©Elsevier).106 B and C, Patient with airway involvement requiring tracheotomy is shown with “beard” involvement at the lip and chin (B) as well as the parotid area and neck (C).
- FIGURE 12
A, Frontotemporal segmental IH typical of PHACE syndrome. B, Sternal clefting characteristic of PHACE syndrome (scar is congenital, not surgical).
- FIGURE 13
Uncomplicated IHs. These lesions generally do not require medical or surgical intervention.
- FIGURE 14
IH of the left eye causing visual field cut and astigmatism. Untreated, the lesion could proliferate, potentially resulting in deprivation amblyopia.
- FIGURE 15
Airway IH extending from the vocal folds inferiorly into the subglottic space, the narrowest region of the pediatric airway. (Photo courtesy of Jonathan Perkins, DO.)
- FIGURE 16
Open rhinoplasty approach to nasal tip IH. These lesions (H) originate within intercartilaginous ligament of the lower lateral nasal cartilages (arrows), rotating them outward.
- FIGURE 17
A, Compound IH of the nasal tip with significant surface involvement. B, Nasal tip after treatment with PDL to salvage tip skin before surgical resection.
- FIGURE 18
Ulcerated IH of the lower lip has resulted in distortion of the soft tissue and obliteration of the vermilion-cutaneous border.
Tables
- TABLE 1
Classification of Cutaneous Vascular Anomalies, 2014
Vascular malformations Venous malformations Lymphatic malformations Capillary malformations Arteriovenous malformations and fistulae Mixed (combined) malformations Vascular tumors Benign Infantile hemangioma (IH) Congenital hemangioma (rapidly involuting [RICH]; non-involuting [NICH]) Lobulated capillary hemangiomas (LCH) (pyogenic granuloma)* Tufted angioma (TA) Others Locally aggressive Kaposiform hemangioendothelioma (KHE) Kaposi sarcoma Others Malignant Angiosarcoma Others Adapted from the International Society for the Study of Vascular Anomalies, 2014, ref 1 (issva.org/classification).
↵* Reactive proliferating vascular lesion
- TABLE 2
Consensus Algorithm for the Diagnosis of PHACE Syndrome
PHACE Syndrome Possible PHACE Syndrome Facial hemangioma >5 cm in diameter plus 1 major criterion or 2 minor criteria Facial hemangioma >5 cm in diameter plus 1 minor criterion Hemangioma of the neck or upper torso plus 1 major criterion or 2 minor criteria No hemangioma plus 2 major criteria Adapted from ref 25.
- TABLE 3
Consensus Diagnostic Criteria for PHACE Syndrome
Organ System Major Criteria Minor Criteria Cerebrovascular Anomaly of major cerebral arteriesDysplasiaa of the large cerebral arteriesbArterial stenosis or occlusion with or without moyamoya collaterals Persistent embryonic artery other than trigeminal arteryProatlantal intersegmental artery (types 1 and 2)Primitive hypoglossal arteryPrimitive otic artery Absence or moderate-severe hypoplasia of the large cerebral arteries Aberrant origin or course of the large cerebral arteriesb Persistent trigeminal artery Saccular aneurysms of any cerebral arteries Structural brain Posterior fossa anomalyDandy-Walker complex or unilateral/bilateral cerebellar hypoplasia/dysplasia Enhancing extraaxial lesion with features consistent with intracranial hemangiomaMidline anomalyc Neuronal migration disorderd Cardiovascular Aortic arch anomaly Ventricular septal defect Coarctation of aorta Right aortic arch (double aortic arch) Dysplasiaa Aneurysm Aberrant origin of the subclavian artery with or without a vascular ring Ocular Posterior segment abnormality Anterior segment abnormality Persistent hyperplastic primary vitreous MicrophthalmiaSclerocornea Persistent fetal vasculature Coloboma Retinal vascular anomalies Cataracts Morning glory disc anomaly Optic nerve hypoplasia Coloboma Peripapillary staphyloma Ventral or midline Sternal defect Hypopituitarism Sternal cleft Ectopic thyroid Supraumbilical raphe Sternal defects Adapted from ref 25.
↵a Includes kinking, looping, tortuosity, and/or dolichoectasia.
↵b Internal carotid artery, middle cerebral artery, anterior cerebral artery, posterior cerebral artery, or vertebrobasilar system
↵c Callosal agenesis or dysgenesis, septum pellucidum agenesis, pituitary malformation, or pituitary ectopia.
↵d Polymicrogyria, cortical dysplasia, or gray matter heterotopia.
- TABLE 4
Treatment Options in the Management of Ulcerated IH
Wound Care Adjuvant Therapies Dressings Antimicrobials White petrolatum–impregnated gauze Metronidazole gel Nonadherent dressings (eg, Mepitel [Mölnlycke Health Care; Gothenburg, Sweden], Telfa [Covidien/Medtronic; Minneapolis, MN]) Mupirocin, gentamicin, bacitracin ointmentPain controlTopical Hydrocolloid dressings (eg, DuoDERM [ConvaTec; Luxembourg]) Anesthetics (eg, lidocaine, benzocaine)Oral Topical agents Acetaminophen with or without narcotics White petrolatum, Aquaphor [Beiersdorf Inc.; Hamburg, Germany], Silver sulfadiazine (Silvadene; Monarch Pharmaceuticals; Bristol, TN) Other Becaplermin gel Topical timolol PDL Early excision Oral propranolol or steroids Adapted from ref 368.
- TABLE 5
Contraindications and Potential Complications Associated With Propranolol Therapy
Contraindications Complications Sinus bradycardia Sinus bradycardia Hypotension Hypotension Greater than first-degree heart block Diarrhea Heart failure Cool extremitiesSleep disturbanceReactive airways Cardiogenic shock Hypoglycemia/seizures Reactive airways Hypoglycemia Hypersensitivity to propranolol hydrochloride Adapted from ref 161.
- TABLE 6
Potential Adverse Effects of Systemic Corticosteroids
HPA axis suppression Cushingoid features Growth deceleration Weight gain/increased appetite Hypertension Gastric irritation Irritability Insomnia Immune suppression Cardiomyopathy Steroid myopathy Osteopenia Ocular adverse effects (glaucoma, cataracts) HPA, hypothalamic-pituitary-adrenal.
