Wound Closure and Gradual Involution of an Infantile Hemangioma Using a Noncontact, Low-frequency Ultrasound Therapy
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Facial hemangiomas, the most benign vascular neoplasms of infancy and childhood, occur in up to 10% of infants and are more common in females and white infants.1,2 Although most hemangiomas do not result in significant complications, some may impinge on vital structures, ulcerate, or bleed. The life cycle of a hemangioma involves a phase of rapid proliferation in the neonatal period, followed by spontaneous involution, usually during childhood.1 The mechanisms that control involution of hemangiomas are still poorly understood but recent evidence seems to indicate that apoptosis (programmed celldeath) may be partially responsible.3 Most infantile hemangiomas involute spontaneously and without sequelae but a sizeable minority will produce complications or need treatment.4,5 Complete involution occurs at an estimated rate of 10% per year; hence, approximately 50% of hemangiomas involute by age 5 years, 70% by age 7 years, and 90% by age 9 years.4
Less than one half of hemangiomas are present at birth; the remainder become evident within the first few weeks of life.1,4 Early lesions may be so subtle they go unrecognized and are often mistaken for a scratch or bruise. Less commonly, a hemangioma may appear as a bright red, flat area resembling a portwine stain. Most hemangiomas are solitary, range in size from a few millimeters to several centimeters in diameter, and may be superficial, deep, or a combination of superficial and deep.4 Superficial presentation is most common and consists of a bright red papule, nodule, or plaque raised above clinically normal skin. In contrast, a deep hemangioma is generally a raised, flesh-colored nodule that often has a bluish hue or an overlying telangiectatic patch. Hemangiomas most commonly occur in the head and neck but may present anywhere in the skin, mucous membranes, or underlying viscera.6
Ulceration is the most frequent complication of infantile hemangioma, occurring in approximately 5% to 13% of patients. Ulceration carries the risk of infection, hemorrhage, and scarring.4 Ulceration results from necrosis and typically occurs in deep, rapidly enlarging hemangiomas. Infants with ulcerated hemangiomas often are irritable, eat poorly, and may have sleep problems. Pain may precede ulceration and is thought to be the result of ischemia and necrosis within the hemangioma.1
The patient was born on December 11, 2006 after an uneventful pregnancy. Shortly after birth, her mother noted a faint pink hue on the left side of the face. Over the first month of life, the pink hue grew rapidly into a large, segmental hemangioma of mixed superficial and deep morphology. An extensive diagnostic work-up revealed no association with PHACE syndrome (ie, no additional related abnormalities). By 1 month of age, the hemangioma was causing significant discomfort and obstructing the patient’s vision. In January 2007, she was started on prednisolone sodium phosphate oral solution (Orapred 15 mg/mL, Ascent Pediatrics, Novato, Calif) at 3 mg/kg and increased to 5 mg/kg in February 2007; however, the lesion continued to enlarge and ulcerate. After approximately 1 month, she was weaned back down to the 3 mg/kg dose.
In February 2007, laser therapy was initiated on an every-fourth-week schedule with moist wound dressings, topical growth factors, and povidoneiodine administered between laser treatments. The laser therapy resulted in some involution of the lesion during 3 months of treatment. Based on the aggressive nature of the lesion, leading experts in vascular malformations planned to place tissue expanders and eventually resect the hemangioma.