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Vascular
Skin Lesions Vascular
skin lesions are very common,
occurring in about 40% of all children. 20 % of hemangiomas are present
at
birth and most begin in the first month of life. Because of their
frequent
occurrence, it is important to have a good understanding of the present
terminology of vascular skin lesion, to be able to differentiate the
lesions, know
when to follow them yourself and distinguish lesions that may need
consultation
with a pediatric dermatologist. Hemangiomas 1.
These
are benign lesions
that are composed of proliferating endothelial tissue. The
lesions are more common in females
(5:1). They usually appear within a few weeks of birth, grow rapidly
and then
stabilize and involute by fibrosis and diminished vascularization.
Usually after
involuting, there is minimal cosmetic defect and <2% require active
therapy.
A third are gone by 3 years of age, 70% by 7 years of age, and 90% by 9
years
of age. a.
Strawberry
hemangiomas
– raised pink lesions that lie in the upper dermis, composed of small,
closely
packed blood vessels b.
Cavernous
hemangiomas
– subcutaneous spongy mass with blue color c.
Mixed -
combination of
cavernous and strawberry
Strawberry
hemangioma 2.
Complications a.
Local
complications
include ulceration, bleeding, and infection. Most bleeding can be
controlled by
simple pressure. Superficial infection can be treated with topical
antibiotic
ointment and non-adhering dressings. Lesions in the anogenital area are
often
difficult to treat and laser therapy may be indicated. b.
Hemangiomas
in vital
areas may need special treatment, especially those around the eyes that
may
affect vision and lead to amblyopia. There may be lesions in the airway
that
cause respiratory compromise and others may interfere with defecation
and feeding. c.
Kasbach-Merritt
syndrome is
characterized
by rapid growth of hemangiomas
associated with thrombocytopenia and bleeding secondary to platelet
trapping
and consumption coagulopathy. d.
Disseminated
neonatal
hemangiomatosis -
multiple skin lesions and also may have visceral hemangiomas
that can lead to high output cardiac failure and bleeding e.
Residua
post
regression -
may
have hypopigmentation, telangiectasia,
scarring, and redundant skin 3.
Treatment a.
Reassure
- Explain the
natural course of the hemangiomas. b.
Encourage
families to
take pictures to document either progression or involution of lesions.
Comparison films help in deciding whether treatment is necessary or has
been
effective. c.
If
lesions are very
large, growing very rapidly, interfering with vital functions, in areas
that
are constantly irritated, or associated with bleeding disorder or heart
failure, referral to a pediatric dermatologist is recommended. d.
Specific
modes of
therapy
i.
Intralesional
(injected) or oral steroids
ii.
Laser
treatments
iii.
Cryotherapy
iv.
Surgical
removal
v.
Cyclophosphamide
vi.
Interferon Salmon
Patches
(“stork bites”) are flat vascular malformations commonly seen in
newborns on the eyelids, glabella, nasal-labial areas and nape of the
neck.
Most fade within the first year of life, although ones on the nape are
more
likely to stay but are usually covered by hair and are cosmetically
insignificant. They are usually bilateral. Some erythema may persist
and be accentuated
by exertion or crying.
Salmon patch Port
Wine Stains are
flat hemangiomas
composed of dilated capillaries. They are present at birth and increase
in size
as the child grows and do not involute by themselves. Their size may
vary
greatly. These occur most commonly
on the face, where they may cause considerable cosmetic disfigurement
and
significant emotional problems. Presently, laser therapy is helpful
starting at
an early age and these children should be referred to centers with
experience
in treating PWS. Some lesions may be effectively covered with special
makeup
products. Sturge-Weber
Syndrome occurs
in 5-8% of
patients with PWS that involve the upper eyelid or forehead. It is
classified
as PWS with distribution of the trigeminal nerve and includes vascular
malformations in the CNS. The syndrome is associated with glaucoma,
seizures,
hemiplegia, and mental retardation.
Port wine
stains on the feet in Sturge-Weber
Syndrome Klippel-Trenaunay
and Parkes Weber
Syndromes
include vascular malformations (port wine stains and varicose
veins) of a limb associated with soft tissue and bone overgrowth. Pyogenic
Granulomas are
characterized by
bright red, raised, often pedunculated lesions composed of endothelial
elements. These may arise at the site of previous trauma. They have a
tendency
to bleed and should be removed by cauterization or surgery.
Pyogenic
granuloma Spider
angioma (nevus araneus, spider
nevus)
is composed of a central feeder vessel with radiating vessels that
blanch with
pressure. They have a predilection for upper extremities and face, but
usually
regress spontaneously in children. References 1.
Aschauer
and VanderKam. Treating
Vascular Birthmarks. Contemporary
Pediatrics. March 2000 2.
Berman
K and Zieve
D. Birthmarks.
A.D.A.M. 3 October 2008. 3.
Case
Records of the
Massachusettes General Hospital. A
Newborn Girl with a Large Cutaneous Lesion, Thrombocytopenia, and Anemia. NEJM.
April 22, 2004 4.
Fishman
SJ and
Mulliken JB. Vascular Anomalies: A Primer for Pediatricians.
Pediatric
Clinics of North America. 1998; 45(6):1455-1477 5.
Haggstrom
A, et al. Prospective Study of Infantile Hemangiomas:
Clinical Characteristics Predicting Complications and Treatment.
Pediatrics. Sept 2006 6.
Hurwitz,
Sidney. Vascular
Skin lesions: Accentuate the Positive.
Contemporary Pediatrics.
September 1992 7.
Jasmin
L and Zieve D. Sturge-Weber
syndrome. A.D.A.M. 14
October 2009 8.
Lehrer
M and Zieve D. Pyogenic
granuloma. A.D.A.M. 28 October 2008 9.
MacFie
C, et. al. Diagnosis
of Vascular Skin Lesions in Children: An Audit and Review.
Pediatric
Dermatology. 2008; 25(1):7-12 10.
Wahrman
J and Honig
PJ. Hemangiomas. Pediatrics
in Review.
July 1994 |
