Incidence and Clinical Factors Associated With Ulceration in Infantile Hemangiomas

Abstract

BACKGROUND

Ulceration is an important complication in infantile hemangiomas (IHs). Prior to the use of β-blockers, the estimated incidence of this complication in a referral population was between 15% and 30%. The incidence and factors associated with ulceration have not been systematically studied since the emergence of β-blocker therapy.

OBJECTIVE

Examine the incidence and clinical predictors for ulceration in IHs.

METHODS

Retrospective study at tertiary referral centers.

RESULTS

Compared with a previous large pre-propranolol cohort study, ulceration occurred at a significantly lower incidence of 11.4%. Clinical factors associated with ulceration included partial segmental morphology, location in the diaper area, and size greater than 5 cm. Higher risk of ulceration in Black patients was observed, suggesting barriers to care including delayed diagnosis and referral to specialty care.

LIMITATIONS

Retrospective design at tertiary referral centers.

CONCLUSION

Compared with reports before the use of β-blockers became widespread, the incidence of ulceration in IHs has decreased. However, it continues to be a relatively frequent complication of IH.

Journal of the American Academy of Dermatology

Incidence and clinical factors associated with ulceration in infantile hemangiomas

J Am Acad Dermatol 2022 Oct 28;[EPub Ahead of Print], E Fernández Faith, SD Shah, M Braun, E Pope, I Lara-Corrales, PM Witman, K Harfmann, F Bradley, R Keesari, K Jackson, A Hallagan, IJ Frieden

Written by



Sarah L. Chamlin MD

This subgroup of the Hemangioma Investigator Group (HIG) reports the incidence and associated clinical factors for ulceration in a retrospective study of 1,722 infants with hemangiomas.  Ulceration occurred in 11.4% of patients and was more common in the diaper area, in lesions greater than 5 cm in size and those of partial segmental morphology.  This study mirrors the prospective trial performed from 2002-2003 by myself and the Hemangioma Investigator Group.  Our incidence of ulceration was 15.8% and was performed in the pre-beta blocker era suggesting effective treatment may prevent some patients from ulcerating.  Once again, data suggests better outcomes for patients since the discovery of beta blocker use for hemangiomas.   

Anecdotally, many hemangioma experts believe that propranolol may worsen or precipitate ulceration in a subgroup of patients.  Therefore, we suggest using a lower dose of propranolol, 1mg/kg/day, for patients with active ulceration or those at high risk for this.  A slow dose escalation follows when the clinical response of ulceration healing is noted. 

TAKE-HOME MESSAGE

• Before beta blockers were widely used for infantile hemangiomas (IHs), the rate of ulceration was between 15% and 30%. In this retrospective study, the rate of ulceration secondary to IHs between 2012 and 2016 was 11.4%. Ulceration was more common in superficial IHs, segmental IHs, indeterminate IHs, IHs ≥5 cm, and IHs located in the diaper area. Black patients were at higher risk for ulceration.

• Beta blockers have reduced the incidence of ulceration in IHs. Certain clinical factors should prompt early initiation of beta blockers to reduce this common complication.

–  Katherine M. Stiff, MD