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Hemangioma Q&A with Dr. Gregory Levitin

Dr. Gregory Levitin

Dr. Gregory Levitin

After writing a recent post about my daughter’s hemangioma and the approach my wife and I plan to take, an internationally recognized physician and specialist in hemangiomas and vascular malformations, Dr. Gregory Levitin, read the article and made a comment about laser treatment.  I asked Dr. Levitin if he would be willing to engage in an online Q&A session about hemangiomas and treatment options.  Below is the Q&A exchange, which will hopefully serve as an additional resource for parents who are investigating hemangiomas and options for the future.

Hemangioma Treatment Options & Considerations

Q: What options are currently available for treating a child’s hemangioma?

Dr. Levitin: Hemangiomas are a unique biologic tumor: they typically present during the first several weeks of life and then grow for up to one year. Each hemangioma is truly unique and needs to be evaluated for treatment based upon the size, location, and age of patient. Current therapies include medical (ie steroids, propanolol), laser (pulsed-dye laser), and surgical excision.

Q: When consulting with parents of a new patient, what do you advise they consider when deciding on treatment options for their child’s hemangioma?

Dr.L: As a specialist, I see my role as providing information and empowering the parents to make the best decision for their child. Having had a daughter with a hemangioma, I can understand the concerns that most parents have when making the decision to begin treatment. When deciding on treatment options with patients and families, I try to keep things simple and clear, so that the benefits of treatment and any associated risks can be easily discussed.

Q: True or False: If given time, hemangiomas will always fade away and disappear on their own?

Dr.L: False! This is perhaps the biggest misconception and predates current practice. All hemangiomas grow for 9-10 months, and then over several years go through a process of involution whereby the hemangioma shrinks in size and fades in color. However, the hemangioma does not “disappear” but rather is replaced by fibrofatty tissue. If the hemangioma was small to begin with, then it may fade to something clinically insignificant; however for larger birthmarks, the hemangioma often results in a residual soft tissue deformity, especially when involving the head and neck.

Q: Is there a scientific way to determine the severity level of a hemangioma and the estimated time it will take to disappear on its own?

Dr.L: Unfortunately, it is impossible to predict which hemangiomas will remain small (the majority) and which ones will progress to large, deforming tumors (minority). The best practice is to constantly reevaluate these on a monthly basis starting at initial presentation through the first year of life, so that we don’t miss the opportunity to intervene early when necessary. However while most hemangiomas do not require treatment, the majority of those occurring on the head and neck, or those on the body that become raised or bulky, do require some form of therapy.

Q: There is a lot of chatter on website forums about the varying success of administering the drug Propranolol on your child’s hemangioma – can you provide some background on the drug and its abilities to treat hemangiomas?

Dr.L: Propanolol is a well known cardiac medication that in one study from France, was shown to reduce the progression and in some cases reverse the growth of hemangiomas. It was initially noted to work best on patients with segmental hemangiomas (ie involving large areas of the face or body), but has also been shown to be intermittently successful for large focal (tumor-like) hemangiomas as well. We have seen that it does not work for all hemangiomas, and so depending on the size of the hemangioma, one has to balance the risks, benefits and need for cardiac monitoring before starting this medication.

Q: Have you found an increase in the popularity/success of any one treatment option?

Dr.L: I have found that treatment success is highly correlated to proper indications; the caveat being that what works for some patients may not work for others, and thus each patient must be evaluated individually to determine what treatment (and when) is appropriate.

Laser Treatment

Q: When do you recommend laser treatments to parents of a child with a hemangioma or other birthmark?

Dr.L: The ideal time to treat a hemangioma is when it is still flat; as it becomes raised, it becomes less sensitive to laser treatment. Thus there is often a window of opportunity during the first several months of life when laser therapy is most effective; laser therapy is also effective during the involutional stage (ie after the growth phase is completed) for treatment of residual stain or dilated vessels.

Q: How many treatments are typically required to ensure the hemangioma no longer appears?

Dr.L: This is quite variable; for some 1 to 3 treatments, for others 4 to 6 treatments. Rather than state at the outset how many treatments are necessary, I prefer to constantly reevaluate the effects of treatment to determine if further treatment is necessary.

Q: How long does an individual laser treatment last?

Dr.L: Laser treatment only lasts several seconds to couple of minutes depending upon the area to be treated.

Q: Is the child put under general anesthesia?

Dr.L: The feel of a laser is similar to a rubber band snapping against the skin; if there are only a few spots to treat, then no anesthesia is appropriate. However if the surface area to be treated is large, then I recommend an inhalational (general) anesthetic for the patient’s comfort.

Q: During laser treatments, do the child patients experience pain? Is there pain after the treatment?

Dr.L: If performed under anesthesia, then the patient does not experience the pain at the time of laser treatment. While the laser causes the skin to darken and appear “bruised”, this is not the case. The darkened color is due to clotting of the fine vessels; while it can appear slightly swollen, it is not painful and patients typically do not require pain medications afterwards.

Q: If there is pain after a laser treatment, can the parents administer a pain reliever (i.e. Tylenol) to help their children?

Dr.L: If the child appears uncomfortable, then a dose of Tylenol should be sufficient to relieve any discomfort. Parents should contact their physician for any signs of severe pain or distress.

Q: Are there any known side-effects as a result of laser treatments (scars, reappearance, etc)?

Dr.L: There is a small chance of ulceration from pulsed dye laser treatment, however this is extremely rare and typically seen in younger infants. Parents need to realize however that many hemangiomas develop ulcerations during the growth phase, and it is my belief that post-laser ulcerations after an initial laser treatment in young infants may simply have unmasked a hemangioma that was prone to ulceration. Furthermore, one of the treatment indications for ulcerated hemangiomas is pulsed dye laser, which has shown to significantly increase the healing rate.

Surgery

Q: When is surgery recommended?

Dr.L: Early surgical excision or debulking is indicated for any hemangioma that threatens the eye, airway, or around the nose or mouth (i.e. affecting vision, feeding or breathing). Other indications include hemangiomas with recurrent ulcerations, bleeding or scarring; for those hemangiomas causing significant soft tissue deformity; or for large bulky lesions that do not show signs of involution or which would ultimately require surgical therapy due to residual fibrofatty tissue.

Q: What is involved with a typical surgery to remove a hemangioma?

Dr.L: This is dependent on the size and location of the hemangioma. Essentially, I try to minimize the appearance of any surgical scars and determine the best timing to perform this so as to minimize the need for future interventions.

Q: What is the recovery time frame for the child?

Dr.L: Surprisingly, most children bounce back quite quickly, and parents are often surprised that they are back to their usual level of activity within a day or so. Sutures may be dissolvable, or may need to be removed in 7-10 days after surgery.

Q: Will he/she experience pain after the surgery?

Dr.L: Incisional pain is typically mild and treated easily with oral pain medications. This usually peaks in the first two days and then is not usually noticeable to most patients after a few days.

Q: Are there any known side-effects from the surgery? How often are scars seen in place of the hemangioma?

Dr.L: If left untreated hemangiomas will often result in atrophic changes to the skin due to loss of collagen, causing the involved skin to look prematurely aged or wrinkled. If an ulceration has occurred, this will often heal with a broad scar that is irregular in appearance. Further, as mentioned earlier, hemangiomas do not disappear but are replaced by fibrofatty tissue often leaving a soft tissue deformity in its place.

Surgery relieves all of the above mentioned deformities and replaces it with a surgical incision that should heal as a linear, white, pencil-thin line. When placed in a desirable location, many scars heal so well as to be minimally noticeable except with close inspection. I often notice that many scars become “blemishes” over time, particularly for patients who are treated early in infancy and childhood.

Wait & See

Q: When do you advise parents take a “wait & see” approach with a hemangioma?

Dr.L: The current recommendation is for all patients with a vascular birthmark to be referred to a specialist at the 4 week well-baby check up or when it first appears. At this time, hemangiomas are in the initial growth phase and most develop slowly or remain small and can be safely watched. I typically follow patients monthly for the first 4-6 months as this is the period when most of the growth occurs. During these monthly evaluations, if the hemangioma remains stable or unchanged, then it is reasonable to continue to follow these for any signs of progression. With close follow up, we are then in a position to recognize any changes in size and/or thickness and begin treatment when necessary.

About Dr. Levitin

Dr. Gregory Levitin is an internationally recognized expert in the treatment of hemangiomas and vascular malformations. You may reach Dr. Levitin via email at drlevitin@gmail.com, or through his website at http://www.vascularbirthmarkcenter.com

3 Responses to “Hemangioma Q&A with Dr. Gregory Levitin”

  1. Vanessa Cortez says:

    This is the most informative piece of information I’ve found online regarding hemangiomas. Thank you so much for posting!

  2. Chanda says:

    This was a great q&a. One of the best things I found about treatment of hemangiomas. I wrote a blog post about my sons Hemangioma and posted a link to this q&a. Thanks so much!

  3. Christine says:

    Wish I would have read this 10 months ago. Great info!

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