July 23, 2012 — Rapid, accelerated growth of infantile hemangiomas often has peaked by the time infants are 8 weeks old, which is much earlier than the red birthmarks are typically assessed by specialists.
Megha M. Tollefson, MD, from the Department of Dermatology and the Department of Pediatric and Adolescent Medicine at the Mayo Clinic in Rochester, Minnesota, and Ilona J. Frieden, MD, from the Division of Pediatric Dermatology, University of California, San Francisco, analyzed parents' photographs, rather than relying on their memories, to assess hemangioma growth. The researchers report their findings in an article published online July 23 in Pediatrics.
Infantile hemangiomas, which occur in about 4% of white infants, are the most common tumors of infancy. Although most infantile hemangiomas do not cause serious morbidities, a significant minority can cause permanent disfigurement, especially if they appear on the face or involve vital organs.
Affected children, on average, are first seen by a pediatric dermatologist at 5 months of age. Dr. Tollefson and Dr. Frieden sought to better understand the dynamics of hemangioma growth in younger infants.
They recruited patients through the University of California at San Francisco pediatric dermatology clinics and via the National Organization of Vascular Anomalies, a patient advocacy group, from January 2009 to March 2011. The researchers sought photographs taken by parents of the infantile hemangiomas every 2 weeks during the infants' first 2.5 months to 6 months of life. Of 72 families expressing an interest in the study, 36 parents returned consent forms, questionnaires, and photos. Six families were excluded because of incomplete materials, inadequate intervals between photos, or poor-quality images. Of the 30 patients in the study, 22 were girls and 8 were boys. Twenty-four patients had superficial hemangiomas, 1 had a primarily deep hemangioma, and 5 had mixed hemangiomas.
The research team analyzed photos up to a mean of 19.1 weeks (median, 20.8; range, 9.4 - 24.9 weeks; 95% confidence interval [CI], 17.4 - 21.2), looking for differences in color, thickness, and anatomic distortion. The most rapid rate of hemangioma growth was from the infant's first day of life to 8 weeks of age (P <.001).
The researchers also compared changes in interval photographs to determine whether the growth was linear or nonlinear. Twenty-nine of the 30 infants were judged to have nonlinear growth, with the greatest infantile hemangioma growth occurring from 5.5 weeks (95% CI, 4.6 - 6.3) to 7.5 weeks (95% CI, 6.7 - 8.4; median, 4.3 - 6.8) of age.
"Our findings suggest the need for a paradigm shift in management: early hemangiomas need to be recognized more promptly, and infants with high-risk hemangiomas should be watched closely (eg, seen weekly or biweekly), have treatment initiated, or be referred to specialists promptly, ideally by 4 weeks of age, because a period of accelerated growth occurs between 5.5 and 7.5 weeks of life," the authors write. They also urge specialists to consider a triage system for reviewing clinical photographs to determine optimal timing of consultation and management.
The study limitations included a relatively small sample size because of the time commitment required from busy parents, a disproportionate number of hemangiomas at the more severe end of the clinical spectrum, and the lack of infants with hemangiomas in the lower half of their bodies. Because the majority of the study participants had primarily superficial hemangiomas, the findings may be less generalizable to deeper hemangiomas, which appear later in life and grow for longer periods.
"As newer, more effective treatments become available, earlier referral and treatment of high-risk hemangiomas may have an even greater potential for preventing hemangioma-related complications and permanent irreversible skin changes or complications," the authors note.
This study was presented as a poster in 2011 at the Society for Pediatric Dermatology Annual Meeting. Dr. Frieden is the Chair of the Data Safety Management Committee of the HEMANGIOL study. Dr. Tollefson has disclosed no relevant financial relationships.
Pediatrics. Published online July 23, 2012.
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