Ulcerated hemangiomas: Clinical characteristics and response to therapy

Background: Hemangiomas represent the most common benign tumor of infancy: with ulceration its most frequent complication. Objective: Our purpose was to review our experience with this challenging problem by evaluating the clinical features, management, and therapeutic responses of ulcerated hemangiomas. Methods: A retrospective analysis of ulcerated hemangiomas at the University of California, San Francisco outpatient pediatric dermatology clinics and Oakland Children's Hospital from 1987 to 1997 was performed. Results: The medical records of 60 patients were examined. Forty-nine female and 11 male patients were seen with a female/male ratio of 4.5:1. The majority of ulcerated hemangiomas were of the plaque type (n = 50; 83%) and relatively large; 47 (78%) were larger than 6 cm(2). The perineum was the single most frequently involved site, affected in 20 cases (33%). Topical antibiotics, barrier creams, and bio-occlusive dressings were used in most cases. Systemic antibiotics were used in 26 cases ( 43%) for overt or presumed infection. Systemic corticosteroids were used in 21 children (37%), 5 of whom did not show a response. Intralesional triamcinolone was used in 7 cases (12%), with 4 showing definite improvement. The flashlamp pulsed-dye laser was the modality used in 22 children (37%), 11 (50%) of whom showed definite improvement, 4 (18%) who showed no significant response, and 1 (5%) who showed definite worsening. Interferon alfa-2a was required in 5 patients (8%), all of whom showed improvement without appreciable neurologic side effects. Immediate surgical excision was required in only 2 cases (3%). Pain control with oral acetaminophen, acetaminophen with codeine, and topical 2.5% lidocaine ointment was effective in managing the pain of lip and perineal hemangiomas, with no side effects noted. Conclusion: No one uniformly effective treatment modality was found, and frequently several were used concurrently. The decision to use specific therapies was dependent on the age of the patient, as well as the location, size, and stage of growth or involution of the hemangioma. Our approach to management included 4 major areas: local wound care, management of infection, specific therapeutic modalities (systemic and intralesional corticosteroids, flashlamp pulsed-dye laser, and interferon alfa-2a), and pain management.