Infantile hemangiomas: risk factors for complications, recurrence and unaesthetic sequelae

Mariani, Letícia Gaertner; Ferreira, Lílian Moraes; Rovaris, Diego Luiz; Bonamigo, Renan Rangel; Kiszewski, Ana Elisa

doi:10.1016/j.abd.2021.05.009

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ORIGINAL ARTICLE • An. Bras. Dermatol. 97 (01) • 2022 • https://doi.org/10.1016/j.abd.2021.05.009 copy

Infantile hemangiomas: risk factors for complications, recurrence and unaesthetic sequelae^* * Study conducted at the Pediatric Dermatology Outpatient Clinic, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

Infantile hemangiomas (IH) occur in approximately 4% to 10% of the pediatric population. The identification of clinical subtypes and conditions that indicate increased risk for complications is essential for therapeutic success.

Objectives:

To identify risk factors for complications, recurrence and unaesthetic sequelae.

Methods:

Retrospective cohort of patients with infantile hemangiomas undergoing follow-up at the Dermatology Service of Universidade Federal de Ciências da Saúde de Porto Alegre, between 2006 and 2018.

Results:

190 patients were included; 24% had some type of complication, ulceration being the most frequent, and 86% required treatment. On correlation, ulceration was statistically related to mixed IH (p = 0.004), segmental IH (p < 0.01) and location in the gluteal region (p = 0.001). The mean time of treatment with propranolol was 12.7 months. Patients with PHACES syndrome and segmental infantile hemangioma required longer treatment (p < 0.001 and p = 0.0407, respectively), as well as those who started treatment after five months of life (p < 0.0001). Recurrence occurred in 16.6% of the treated patients, all-female; 94% were located on the head and neck (mainly on the upper eyelid, cyrano, S3 segment, and with parotid involvement); 61% and 38.8% were of the mixed and deep subtypes, respectively. Approximately 1/3 of the patients had some unaesthetic sequelae.

Study limitations:

As this is a retrospective study, data and photos of some patients were lost. Conclusions: Mixed and segmental hemangiomas are risk factors for ulceration and sequelae. Recurrence occurs more often in females and segmental hemangiomas. Segmental infantile hemangioma and PHACES syndrome require a longer time of treatment. Specific protocols are required for infantile hemangiomas with a high risk of recurrence.

KEYWORDS
Hemangioma; Propranolol; Recurrence; Risk factors; Scars

Variables
Sex - n (%)	190 (100)
Female	138 (72.6)
Male	52 (27.3)
Morphological subtype - n (%)	176 (93)
Superficial	54 (30.6)
Mixed	110 (62.5)
Deep	12 (6.8)
Location - n (%)	187 (98)
Head and neck	140 (74.8)
Anogenital	14 (7.4)
Outro	75 (40.1)
Clinical subtype - n (%)	185 (97)
Focal	133 (71.8)
Segmental	36 (19.4)
Multifocal	16 (8.7)
PHACES syndrome	9 (4.8%)
Delivery - n (%)	127 (67)
C-section	102 (80.3)
Vaginal	25 (19.6)
Family History of IH - n (%)	89 (47)
Yes	19 (21.3)
No	70 (78.6)
Premature birth (<37 weeks) - n (%)	145 (76)
Yes	40 (27.5)
No	105 (72.4)

	p-value	n
Clinical subtype Cyrano	0.8752	120/89
PHACES	<0.0001	120/89^a
Multifocal IH	0.7953	120/89
Segmental	0.0407	123/89^b
Morphological subtype Superficial	0.7747	120/89
Mixed	0.4959	120/89
Deep	0.3167	120/89
Location Head and neck	0.1196	121/87
Anogenital	0.1361	121/87
Lips	0.4820	123/89
Nose	0.0718	123/89
Ear	0.1231	123/89
Other	0.3215	121/87
Ulceration	0.0088	123/89
Start of Propranolol (before or after 5 months)	< 0.0001	122/88^c

Patient	Body segment	Subtype	Morphology	Topography	Age at the start and end of treatment	Age at recurrence	Treatment
1	Head and neck	Deep	Focal	Upper lid	Start: 7m	1a 9m	PPL
2	Anogenital area	Mixed	Focal	Vulva	End: 1a 6m Start: 2m	1a 2m	PPL + prednisolone
3	Head and neck	Mixed	Segmental	S1, S2, S3, S4, parotid, cyrano, upper lid PHACES	End: 1y 1m Start: 2m	5a	PPL
4	Head and neck	Mixed	Segmental	S2, S3, parotid, lower lip PHACES	End: 2y Start: 2m	4a	PPL
5	Head and neck	Deep	Focal	Upper lid	End: 2y Start: 5m	1a 7m	PPL
6	Head and neck	Deep	Focal	Cyrano	End: 1y 4m Start: 1m	1a 3m	PPL
7	Head and neck	Mixed	Segmental	S1, S2, upper lid	End: 8m Start: 3m	2a 2m	PPL
8	Head and neck	Mixed	Segmental	S1, S2, S3, cervical, parotid, upper lid	End: 1y 8m Start: 3m	3a	PPL + prednisolone
9	Head and neck	Deep	Focal	Cyrano	End: 1y 7m Start: 2m	4a 7m	PPL
10	Head and neck	Deep	Focal	Upper lid	End: 3y 2m Start: 6m	3a 4m	PPL
11	Head and neck	Mixed	Segmental	S3, cervical, lips, PHACES	End: 2y 1m Start: 3m	3a	PPL + prednisolone
12	Head and neck	Deep	Focal	Upper lid	End: 2y 10m Start: 4m	1a 3m	PPL
13	Head and neck	Mixed	Focal	Cyrano	End: 8m Start: 3m	1a 4m	PPL
14	Head and neck	Deep	Segmental	S3, parotid	End: 1y Start: 6m	2a 6m	PPL
15	Head and neck	Mixed	Segmental	S3, parotid, lip, PHACES	End: 2y 5m Start: 3m	4a	PPL + prednisolone
16	Head and neck	Mixed	Segmental	S2, S3, cervical, lips, PHACES	End: 1y 3m Start: 3m	3a 10m	PPL
17	Head and neck	Mixed	Segmental	S4, lips, cyrano	End: 3y Start: 2m	6a	PPL + prednisolone
18	Head and neck	Mixed	Segmental	S2	End: 2y 1m Start: 8m End: 2y 10m	3a 5m	PPL

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E-mail: revista@sbd.org.br

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[1] *Corresponding author. E-mail:kiszewski@gmail.com (A.E. Kiszewski).

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Infantile hemangiomas: risk factors for complications, recurrence and unaesthetic sequelae* * Study conducted at the Pediatric Dermatology Outpatient Clinic, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.

Abstract

Background:

Objectives:

Methods:

Results:

Study limitations:

Infantile hemangiomas: risk factors for complications, recurrence and unaesthetic sequelae^* * Study conducted at the Pediatric Dermatology Outpatient Clinic, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.