Hemangiomas: To Refer or Not To Refer?

Hemangiomas are the most common tumors seen in infants. Despite their rapid growth early in life, often the only action required of the physician is to reassure the parents that such tumors usually involute spontaneously during childhood. However, this is not always the case- and it can be hard to tell which hemangiomas will resolve without a trace, which will result in disfigurement or scarring, and which may involve organs other than the skin. Thus, it is difficult for pediatricians to decide whether and when to refer affected infants to specialists.

A recent cohort study by the Hemangioma Investigator Group may provide some welcome guidance in this area.¹ The study involved patients from 7 pediatric dermatology practices in the United States and 1 in Spain; it examined hemangioma growth patterns and time of referral to specialists. A total of 526 hemangiomas were followed in 433 patients; the size, growth stage, and morphology of each lesion, and the depth of skin involvement were assessed. The investigators also noted the age at which parents noticed the lesion and when the child was brought to a dermatologist.

The study determined that the largest increase in size occurred by age 5 months, at which point most hemangiomas had reached 80% of their final size. Differences in absolute size were found to be related to hemangioma subtype (with the mean size of segmental hemangiomas 10 times that of localized hemangiomas); however, the growth patterns of the various subtypes were similar.

Little difference in growth was seen between treated and untreated lesions. However, this finding may have been the result of the window of opportunity for favorable treatment having been missed (current treatments are more effective at stopping growth than at promoting involution once growth has occurred). The authors acknowledge that the lack of difference between treated and untreated lesions may also have been the result of selection bias, or of the fact that available treatments are only partially effective.

By 1 month of age, most hemangiomas had been noticed by parents; however, the average age at which patients first saw a dermatologist was 5 months. By that time, most hemangiomas had attained much of their final size, may already have given rise to complications, and were past the point of optimal treatment. Thus, the authors recommend that primary care physicians expedite referrals for hemangiomas that are more likely to produce complications or to require treatment; they also recommend that specialists prioritize making appointments for referred infants to minimize treatment delays.

Infants considered by the authors to be at highest risk for complications or associated problems include those with hemangiomas that involve:

• Large areas of the face.

• The nose.

• The ear.

• The eye area.

• Around the mouth.

• The "beard area" or neck.

• The region overlying the lumbosacral spine.

• The axilla.

• The perineal area.

In addition, infants with multiple hemangiomas may have visceral involvement and thus are also considered high risk.

As the authors point out, this study has several limitations, including a referral bias and a lack of standardized intervals of assessment of hemangiomas. Although the majority of hemangiomas included were localized, the lesions studied were ones for which a dermatology referral had been made and may thus have been higherrisk hemangiomas. Also, although there may have been a delay between the time of parental appreciation of a hemangioma and the time of the first visit to a dermatologist, the time at which referral was made by the primary care practitioner was not noted. Thus, it is possible that some referrals were made early on and that delays were caused by the wait for a dermatologist appointment.

Despite these limitations, the study emphasizes the need for frequent and careful evaluation of infantile hemangiomas, as well as for immediate referral of infants with high-risk lesions. By increasing our awareness of potentially problematic hemangiomas, we can help our patients receive treatment in a timely manner and hopefully obtain more successful results.

References:

• Hemangioma Investigator Group; Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. 2007;150:291-294.