Overview
Definition:
Hemangioma ulceration refers to the breakdown of the skin overlying a superficial infantile hemangioma, leading to a painful open wound
Infantile hemangiomas (IH) are benign vascular tumors of infancy that undergo rapid proliferation followed by involution.
Epidemiology:
IHs occur in 3-10% of infants, with ulceration being a common complication, especially in those that are superficial, large, or located in areas subject to friction or pressure
Ulceration rates vary from 5% to over 20% depending on the IH subtype and location
Risk factors include prematurity and certain genetic syndromes.
Clinical Significance:
Ulcerated hemangiomas are painful and can lead to significant morbidity in infants and children
Complications include infection, scarring, disfigurement, and functional impairment, particularly if located on the face or near vital structures
Effective wound care and pain management are crucial for patient comfort and optimal healing.
Clinical Presentation
Symptoms:
Chief complaint of pain or discomfort
Irritability and inconsolable crying
Poor feeding
Signs of local infection such as erythema, warmth, and purulent discharge
Bleeding from the ulcerated area.
Signs:
Visible ulceration on the surface of a hemangioma, often with a red, raw base
Surrounding skin may be erythematous and edematous
Crust formation is common
Satellite lesions may be present
In severe cases, surrounding cellulitis or lymphadenopathy may be observed.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the characteristic appearance of an ulcerated lesion within a known or suspected infantile hemangioma
Biopsy is rarely indicated but may be considered for atypical presentations or to rule out other diagnoses.
Diagnostic Approach
History Taking:
Detailed history of the hemangioma's evolution
Onset and duration of ulceration
Assessment of pain levels and impact on feeding/activity
History of trauma to the area
Previous treatments and their efficacy
Signs of systemic illness or infection.
Physical Examination:
Thorough examination of the ulcerated hemangioma, noting its size, depth, and location
Assess for signs of secondary infection (erythema, warmth, purulence, fever)
Palpate for lymphadenopathy
Evaluate for functional impairment (e.g., visual obstruction, airway compromise).
Investigations:
No specific laboratory investigations are routinely required for uncomplicated ulcerated hemangiomas
If infection is suspected, a complete blood count (CBC) and C-reactive protein (CRP) may be useful
Blood cultures and wound cultures may be considered in cases of severe sepsis
Imaging (ultrasound, MRI) may be helpful for large or deeply infiltrating hemangiomas to assess extent and involvement of underlying structures, but not typically for routine ulceration management.
Differential Diagnosis:
Other causes of ulcerated lesions in infants include: infected eczema, folliculitis, contact dermatitis, herpes simplex virus infection, pyoderma gangrenosum (rare), and traumatic ulcers
Distinguishing features include the underlying vascular nature of hemangiomas and their characteristic proliferative and involuting phases.
Management
Initial Management:
Gentle cleansing of the wound with saline or a mild antiseptic solution (e.g., dilute chlorhexidine)
Debridement of loose necrotic tissue if present, to promote healthy granulation
Application of a topical antibiotic ointment (e.g., mupirocin or bacitracin) to prevent secondary bacterial infection.
Wound Care Protocols:
Use of non-adherent dressings to protect the ulcerated surface and minimize pain during changes
Options include silicone-based dressings, hydrogel dressings, or petroleum-impregnated gauze
Dressing changes should be performed as needed, typically daily or every other day, or when soiled or loose
The goal is to maintain a moist wound healing environment.
Pain Control:
For mild to moderate pain: topical anesthetics (e.g., lidocaine gel) can be applied cautiously before dressing changes
Oral analgesics like acetaminophen (paracetamol) or ibuprofen are effective for systemic pain relief
Doses should be adjusted based on weight and age
For severe pain or significant distress, consider short-term, low-dose oral opioids under close supervision.
Pharmacological Treatment:
Systemic propranolol is the first-line treatment for symptomatic or problematic hemangiomas, including ulcerated ones, as it can accelerate healing and reduce pain
Typical starting dose: 1 mg/kg/day orally, gradually increased to 2-3 mg/kg/day divided into 2-3 doses
Topical timolol 0.5% gel can be used for small, superficial ulcerations
Oral corticosteroids may be used for rapidly growing or life-threatening hemangiomas that do not respond to propranolol, but are generally reserved for severe cases due to side effects.
Supportive Care:
Nutritional support is vital, especially if feeding is affected by pain
Monitor for signs of dehydration and infection
Provide comfort measures and reassurance to the infant and caregivers
Educate caregivers on proper wound care techniques and warning signs of complications.
Complications
Early Complications:
Secondary bacterial infection leading to cellulitis or abscess formation
Bleeding
Persistent pain and irritability
Dehydration due to poor feeding
Disruption of wound healing.
Late Complications:
Significant scarring, including hypertrophic scars or keloids
Telangiectasias within the scar
Residual dyspigmentation
Functional impairment if near critical structures (e.g., vision, airway).
Prevention Strategies:
Early recognition and management of superficial hemangiomas with propranolol can reduce the incidence of ulceration
Careful management of any developing superficial lesion to prevent trauma
Prompt and aggressive treatment of any signs of ulceration or infection
Appropriate pain management to ensure adequate feeding and comfort.
Prognosis
Factors Affecting Prognosis:
Size, depth, and location of the hemangioma
Presence and severity of ulceration
Promptness and efficacy of treatment
Development of complications such as infection or significant scarring.
Outcomes:
With appropriate wound care and pain management, most ulcerated hemangiomas heal within weeks to months
Scarring is common but often improves over time
Functional deficits are less common with timely and effective intervention
Systemic propranolol therapy has significantly improved outcomes for many infants with problematic hemangiomas.
Follow Up:
Regular follow-up is necessary to monitor wound healing, assess for pain control, and evaluate the involution of the hemangioma
Long-term follow-up may be required to manage residual scarring or functional issues
Caregivers should be advised on when to seek medical attention for recurrence or new concerns.
Key Points
Exam Focus:
Ulceration of hemangiomas is common and painful
Propranolol is first-line medical management for symptomatic IHs, including ulcerated ones
Topical antibiotics and moist wound care are essential
Pain control is paramount for infant well-being and feeding
Distinguish from other pediatric ulcerative lesions.
Clinical Pearls:
Always consider pain in an irritable infant with a hemangioma
Aggressive pain control with oral analgesics (acetaminophen/ibuprofen) and careful consideration of topical anesthetics can greatly improve infant comfort
Secure dressings are key to preventing further trauma and allowing healing
Educate parents thoroughly on home care to ensure compliance.
Common Mistakes:
Underestimating the severity of pain and its impact on feeding
Inadequate pain management
Using occlusive dressings that may macerate the skin
Delayed referral for systemic medical management (propranolol) for problematic hemangiomas
Neglecting signs of secondary infection.