Haemangioam Dr Kamal Hussain Saleh-consultant Cosmetic Plastic Surgeon-al Emadi Hospital-qatar-doha

The steroid benefit in treating complicated hemangioma Author: Dr. Kamal H. Saleh M.B.CH.B.(F.I.C.M.S.),HEAD OF PLASTIC SURGERY DPARTMENT IN AL EMADI HOSPITAL-QATAR-DOHA Key word: diluted steroid, complicated hemangiomas.

Abstract The clinical study included (30) patients with complicated cutaneous hemangioma (ulceration, bleeding, obstruction of anatomical orifices, & interference with function or movement). Those patients studied regarding the age group, sex, site of lesion, size of lesion, & the percentage of regression after treatment with steroid. The range of age was from 3 months to 6 years, 20 patients were female & 10 patients were male. We use local injection of diluted Triamcinolne 4mg with 5ml NACL 0.9% (normal saline), injected by 23gage syringe under local or general anesthesia every 2 weeks for 6 – 8 sessions depending on the severity of case then applying local pressure dressing. We measure the size of the lesion before each session &record the regression of the lesion. The patients followed for 2 years. Hemangioma commonly present in infant & children, most commonly in female, especially in head & neck in small size between (1*1 –2*4). It will regress early if we start the treatment earlier.

1

Introduction Haemangioma are immature rests of vasofomative tissue that demonstrate angioblastic proliferation & regression &represent the most common vascular tumor of the childhood(1). Infantile hemangiooma which is more common in the females, occur in 10% of the children, usually appear at birth or with in a few weeks after birth, about (30-90)% of cases undergoes characteristic proliferation phase that lasts between 6 – 12 months this proliferative period is followed by stable phase finally followed by period of regression or involution (2), usually between the (10-12) years(3). Infants with the cutaneous hemangioma may treated medically with high dose of steroid for controlling alarming hemangiomas, however only 2/3 of these hemangioma regress or stabilized (4), & well defined surgerybeing planned for esthetic correction at the age of 8-10 years(5) or improve sign and symptoms of infantile hemangiomas (6). The size of hemangioma and the age of initiation of the treatment are the most important factors affecting the response of treatment (7).. the site of lesion and the phase of the hemangioma are affecting too (8). The age of initiation with steroid usually at 7.5 months & the treatment may continue for as long as 5 months (9). Selection type of steroid & the root of administration & the dose schedules wil be guided by clinical experience(10), intralesional injection of steroid is an effective treatment for hemangioma of the head & neck (7), with injection pressure exceeding the systemic arterial pressure routinely occur during intralesional injections steroid into capillary hemangiomas (11).

2

Patients and methods Thirty patients with complicated hemangioma (ulceration, bleeding, obstruction of anatomical orifice, & interfere with function or movement) of different age groups collected by simple random sampling in out patient, cases treated with local injection of diluted triamcinolone 4mg with 5ml normal saline in multiple sessions with 2 weeks apart. The age of patients were from 3 months – 6 years, 20 patients are females & 10 patients are males. We used traditional syringe for injection (23 gage) under local or general anesthesia, then applying local pressure dressing, we repeat the procedure every 2 weeks for 6 – 8 sessions depending on the severity of case, we measure the size of the lesion before each session to record the regression of the lesion.

Results In our 30 patients that visit the outpatient clinic, we find that the most common age group present with hemangioma were females in about 20 patients compared with males in about 10 patients as shown in figure (1). Fig (1):- show the sex difference in haemangioma

20 20

10

15 No .of cases

10 5 0 Female

Male

Sex

Female

Male

3

Also we find that the age presentation to clinic were 10 patients < 1 year, 10 patients from 1 year - < 4years, & 10 patients from 4 years - < 6 years, as shown in the figure (2). Fig (2):- show the no. of cases of Haemangioma according to the age 10

10

10

10 8 No . of cases

6 4 2 0

<1 year <1 year

1year-<4years Age 1year-<4years

4years-<6years

4years-<6years

We found that the most common site of hemangioma in the patients was head & neck in about 51%, the second most common site was the trunk 33%, the extremities 13%, & the genitalia 3%, as shown in figure (3). Fig ( 3 ):- show the most common site of cutanous hemangioma.

Extremities 13 %

Genitelia 3%

Head & neck 51 % Trunk 33 %

Head & neck

Trunk

Extremities

4

Genitelia

We found also that 10 patients the size of cutaneous hemangioma was (1*1cm), 8 patients was (1*3cm), 7 patients was (2*4cm), & 5 patients was (3*5cm), as shown in the table (1).

Number of cases Size in cm 10 cases

1*1 cm

8 cases

1*3 cm

7 cases

2*4 cm

5 cases

3*5 cm

After treatment we found that the 60% of cutaneous heamangioma regress in age group between 1-<2 years old, from 2-4 years old regress in about 40%, & >6 years old is about 25% as shown in table (2).

Age of patient 1 - <2 years 2–4 >6

% of regression 60% 40% 25%

5

No. of patients 10 10 10

We found that only three patients suffer from the complication of steroid treatment, as shown in figure (4).

Fig ( 4 ):- show the complications after treatment of haemangioma

2cases 2 1 case No . of cases

1.5 1

0.5 0

infection

moon face

1

type of complication infection

moon face

Discussion In our (30) patients of cutaneous haemangioma, we found that the most common age group presented with hemangioma was in infant & children (3 months – 6 years) in all patients we treat this agrees with the study of Winter-H, etal. Who found that 65.3 % was infant & children.(3) The female to male ratio was found to be 2:1, this agrees with the Garzon-M who found that hemangioma occur in female 3 times more than male.(9) Hemangioma present commonly in head & neck region in about (51%), then trunk in (33%), extremities in (13%), & genitalia in (3%). This agrees with the study conducted by Mullkin & Glowacki, who found that (60%) of hemangioma are in the head and neck area, (25%)in the trunk, & (15%) in the extremities.(12)

6

We found that the majority of hemangioma was small in size in about (83.3%) in 25 patients & (16.7%) in 5 patients. This agrees with the study of Garzon-M.(9) After treatment with local steroid the percentage of regression was found to be (60%) when we start the treatment in early period 3 months - <2years, (40%) from 2 - <4 years,& (25%) from 4 – 6 years. This agrees with the Akyus – C, etal, who found that the age of initiation of treatment is the most important factor affecting the response to treatment.(1`)

References 1 -Akyuz – C. management of cutaneous hemangioma . pediatr- hematol-oncol.2001 Jan-Feb; 18(1);47-55. 2-10-Sadan

– N. treatment of infants with high doses of prenisolone, J – pediatr. 1996 Jan;128(1); 141-6. 3-Winter- H, etal. Sclerotherapy in treatment of hemangioma. Dermatol – surg. 2000 Feb; 26(2);105-8.

4-Leatue –labreze – C. sever hemangioma. Ann – dermatolvenreal.1998 Mar;125(3);174-fer8. 5-Park-E-A . Infantile hemangioma. J.Korean-Med-Sci.2001 Feb;16(1); 127-9. 6--Mokni – M. pyoderma gangrenous. Hoso- pract- (off-end). 2001 April-15; 36(4); 40-4. 7 -Egbert-J-E. High injection pressure in capillary hemangioma. Arch- ophthalmol.2001 May; 119(5); 677-83.

7

8 Buyukpamukeu – M. Cutaneous hemangioma. Pediatrhematol-oncol.2000 March –16(1):33-36 9-Garzon – M, etal. Hemangioma update on classification, cutis.2000 Nov;66(5);325-83. 10-Bennaceur – S. mucocutaneous hemangioma in children,Rev- stomatol-chirmaxillofac. 2000 Jan;101(1);17 11-Mulkin & Glowacki. Hemangioma & vascular malformation of the head and neck.1989 May; 34(3);156-98

12--Sean Boutros. Hemangioma of the face. Perspective in plastic surgery, 2000: v-14; N.1, p45.

8