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Five infantile hemangiomas? Check the liver.


SAN FRANCISCO -- Infants with five or more hemangiomas should undergo a liver ultrasound according to new research, said Dr. Ilona J. Frieden.

Clinicians know that when they see infants with multiple cutaneous hemangiomas, they need to worry about internal hemangiomas, said Dr. Frieden at the seminar, sponsored by Skin Disease Education Foundation (SDEF). And now, for the first time, a prospective, multicenter study identified how many infantile hemangiomas should trigger alarm.

The study screened infants younger than 6 months in the United States, Canada, and Spain with abdominal ultrasound and found that 16% of 151 infants with five or more skin hemangiomas had liver hemangiomas, compared with no liver hemangiomas in a control group of infants with one to four skin hemangiomas, she said.

"We certainly recommend doing liver ultrasound in children with five or more hemangiomas," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco. "Five does seem to be the right threshold for doing this screening test."

Interestingly, only 2 of the 24 infants with hepatic hemangiomas received treatment specifically for the hepatic hemangiomas (Pediatr. Dermatol. 2011;28:245-53). "Liver hemangiomas are probably a lot like skin hemangiomas--they don't all need treatment. That's an important fact," she said.

In general, segmental hemangiomas are more likely to develop complications, and facial segmental hemangiomas are more likely to need systemic treatment. The main indication for treating cutaneous infantile hemangiomas is a risk of scarring and disfigurement, especially with facial segmental hemangiomas, ulcerated hemangiomas, and hemangiomas located on the ear or on any prominent facial site but especially the nasal tip or perioral areas.


Treatment should also be considered in patients with periocular or liver hemangiomas, hemangiomas of the airway, spinal dysraphism or genitourinary complications, or in PHACE syndrome, she said.

A previous study by Dr. Frieden and her associates showed that 30% of infants with large facial hemangiomas will have PHACE syndrome (Pediatrics 2010;126:e418-26).

Dr. Frieden, who placed a leading role in defining PHACE syndrome, estimated it to be a more common neurocutaneous syndrome than Sturge-Weber: "Not super-rare, but not common," she said.

Any infant with a facial hemangioma measuring 5 cm or more in diameter probably deserves cardiac echocardiography to look for transverse coarctation of the aorta, MRI and magnetic resonance angiography to look for arterial anomalies, and an eye exam to look for structural eye abnormalities even if there is no periocular hemangioma, she advised.

Infants with lumbosacral hemangiomas are at greater risk for having a tethered spinal cord or other problems such as genitourinary abnormalities. About half of infants with typical lumbosacral hemangiomas will have a tethered spinal cord, prospective studies suggest. Lumbosacral hemangiomas tend to stay flatter and less bulky than hemangiomas on other body areas and so may not raise the suspicion of problems that would be warranted. Dr. Frieden has diagnosed tethered spinal cord in several infants with lumbosacral hemangiomas who were referred only after they developed ulcerations.

Dr. Frieden has had ties to Pierre Fabre and Topaz Pharmaceuticals.

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Title Annotation:CLINICAL ROUNDS
Author:Boschert, Sherry
Publication:Pediatric News
Article Type:Clinical report
Date:Dec 1, 2011
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