Hemangioma Recurrence: Prevention And Management

Introduction

A haemangioma can be defined as a benign vascular tumour.¹ The difference between a haemangioma and other vascular malformations is mainly due to how it grows. Haemangiomas grow rapidly and then decrease in size slowly after a certain amount of time.² 

The appearance of haemangiomas varies depending on where it is located and the area it covers. Haemangiomas located near the surface of the skin are often bright red, raised growths, which are sometimes called “strawberry” marks, whereas haemangiomas deeper in the skin look like soft lumps, which give the overlying skin a blue colour.³ Localised haemangiomas look like large bumps that are contained in one part of the body, whereas segmental haemangiomas are more plaque-like in appearance and cover a larger part of the body.⁴

There has been a lot of confusion on the characterisation of hemangiomas, with early studies combining venous malformations and hemangiomas into the same category. These are now separate conditions. Cavernous hemangiomas are a type of angioma, which have a different onset to hemangiomas.

Prevalence and risk factors

Haemangiomas are the most common benign growth in children, with 1-2% of newborns having the condition and 3-10% of infants up to 12 months developing growth after birth.^{1, 3} Typically, they are more common in people assigned female at birth (AFAB) than people assigned male at birth (AMAB).^{1, 4,5} 

Haemangiomas are caused by changes in the body's processes that form new blood vessels; however, the reasons behind this are disputed.⁴ Studies have shown, however, that increased maternal age, premature birth and the mother having multiple gestations all may increase the risk, with low birth weight of the child carrying the highest risk.⁶ Haemangioma formation is thought to be caused by low oxygen exposure in the womb, which indicates they are congenital.

Hemangioma recurrence: understanding risk

Contributing factors

Recurrence of haemangioma is dependent on the type and location of the tumour in the body. Growths on the skin are more common and are therefore more likely to recur; however, there are isolated cases of haemangiomas that affect muscles, bone, and organs, which have been shown to return following treatment or surgical removal.

A certain proportion of infants treated with beta-blockers also experienced recurrence caused by early termination of treatment, which allows lesions to “re-grow.” Recurrence can also be caused by resistance to the medication being used.

Prevention strategies for recurrence

Medical interventions

1. Beta-blockers^{7, 8}

Propranolol causes blood vessels that make up the haemangioma to constrict and, as a result, cause the tumour to shrink.

Benefits:

• Effective at decreasing the size and recurrence of all types of haemangioma
• Safe 
• Well-documented side effects

Negatives:

• Rebound growth following stopping treatment early
• It can cause hypoglycaemia (low blood sugar)
• It can cause asthma attacks in patients with a history of asthma
• Can affect sleep
• Decreased blood pressure can cause cold hands and feet.

The negative side effects of propranolol are dependent on the patient's medical history and occur in small proportions of people. The dose required to treat haemangiomas is relatively low and the incidence of negative effects seems to occur in patients receiving much higher doses. When the beta blocker is stopped the majority of these side effects also stop.⁷

Recurrence of the haemangioma is more likely if propranolol is stopped earlier in the treatment. There is some evidence that rebound growth is caused by residual lesions that remain after treatment is stopped, and a second course of propranolol prevents recurrence.⁷

2. Steroids^{7, 8}

Oral corticosteroid therapy with medicines such as prednisolone can interrupt systems in the body that promote the growth of the haemangioma.

Benefits:

• Can be used in combination with beta-blockers 
• Highly effective in most cases 

Negatives:

• Some haemangiomas are resistant to steroids
• Many side effects: Heartburn, weight gain, rounding of the face, acne, effects on the heart muscle
• Can increase the risk of infection

The negative side effects of steroids are more common than beta-blockers and as a result, require more follow-up.

Injection of corticosteroids directly into the superficial haemangioma is another treatment option.

Benefits:

• Rapid reduction in size following the initial injection
• Decreased side effects on the body compared to beta blockers
• Better for haemangiomas that are close to the nose, lips or eyes

Negatives:

• Chance of recurrence following the initial injection
• Local skin damage caused by the injection
• Many patients changed to propranolol after rebound growth following the injection
• Only effective for small haemangiomas

Surgical options

1. Considerations for removal

Haemangiomas may be physically removed for several reasons:

• Eyesight is affected
• Interferes with other parts of the body, which affects daily tasks such as eating
• Haemangiomas on the nose as they decrease in size very slowly and can affect the cartilage in the area
• The growth is causing psychological distress.⁹
• Resistance to medication

2. Laser therapy:

Laser therapy is effective in treating complicated haemangiomas that have formed an ulcer. When a haemangioma ulcerates it forms an open wound on the skin that causes pain, bleeding, and increases the risk of infection. Laser treatment allows endothelial cells to repair the ulcer and is more effective in healing the open wound and reducing discolouration of the haemangioma, as opposed to decreasing its size.¹⁰

Management approaches for recurrence

Follow-up and monitoring

Most haemangioma patients will receive monitoring at set points during the treatment and then up to two years post-treatment to monitor the progression of growth and determine effectiveness. Depending on the type of hemangioma, this may require the use of imaging such as ultrasound or X-ray if the haemangioma is found in deeper tissue.

Behavioural modifications

1. Sun protection:

UV light can increase the swelling and redness associated with haemangiomas and as a result, can negatively impact treatment. Patients should use a high-factor sunscreen (factor 50) when they are outside, even if it is cloudy. Sunlight can still penetrate through the clouds so suncream must be always applied before leaving the house.

2. Psychological support:

Children who are suffering from psychological problems as a result of their haemangioma may benefit from skin “camouflage” which can be provided by the Changing Faces Charity.

Medical interventions

1. Systemic treatments:

Doctors may intervene with systemic treatment as a result of negative side effects associated with the medication. As noted above, there are numerous side effects associated with both propranolol and prednisolone (with propranolol having less incidence and prednisolone causing profound implications with long-term use). Treatment may also be altered if there is no benefit to limiting negative effects in response to poor response to medication.

2. Topical treatments:

Topical treatments are more likely to be stopped in response to poor response. Topical timolol is effective in treating smaller haemangiomas, however, it is of limited use in larger growths and haemangiomas that require a more urgent response.

Surgical options

1. Excision and reconstruction:

Excision is primarily used for patients in whom function is impaired. Patients with smaller haemangiomas have better results, as the growth can be completely removed, allowing for better skin texture and colour. However, surgical intervention is the most invasive and larger haemangiomas can leave scarring.

2. Minimally invasive procedures

Minimally invasive options for treating hemangioma recurrence typically involve procedures such as embolisation or sclerotherapy. 

Embolisation involves blocking blood flow to the hemangioma by injecting small particles or a clotting agent into the blood vessels feeding it. Sclerotherapy uses a chemical agent injected into the hemangioma to shrink it by causing irritation and scarring of the blood vessel walls. 

Both techniques are effective in managing recurrent hemangiomas with minimal risk and quicker recovery compared to traditional surgery.

Summary

The majority of hemangiomas will resolve by themselves, and many doctors will wait to see if any intervention is required. It is also important to note that in the case of intervention, most cases will respond and decrease in size. When medical intervention is required, propranolol is considered first-line therapy due to its effectiveness. Corticosteroids are now used less frequently due to side effects, however, they are still useful when the response to propranolol is incomplete. Surgery and laser treatment are reserved for complicated cases which interfere with nearby structures and have success rates. Recurrence of hemangiomas is also manageable, and therapy is usually decided on a case-by-case basis. There is still a lot to be learned about hemangiomas, and current treatments are by no means exhaustive. Research is still being carried out into the reasoning why hemangiomas form, and new theories often allow doctors to employ new techniques to treat the condition.