Answer:
Approximately 20% of hemangiomas cause endangering complications such as major ulceration/destruction, distortion of involved tissues, or obstruction of a vital structure. Spontaneous ulceration of the involved skin can extend into the deeper tissues and lead to partial loss of the eyelid, ear or lip. An orbitopalpebral hemangioma can block the visual axis and cause deprivation amblyopia. Even a small hemangioma in the upper eyelid can distort the growing cornea, producing astygmatic amblyopia. Subglottic hemangioma presents with biphasic stridor. More rarely, life threatening complications can occur such as diversion of blood flow through a large cutaneous hemangioma or hepatic hemangioma resulting in high-output cardiac failure.
A well-localized hemangioma can be treated with intralesional steroids, 3-5 treatments at 6-8 week intervals. Systemic corticosteroids are the first line treatment for either large, destructive, endangering or life-threatening hemangiomas. Oral prednisone is given for 4-6 weeks and then tapered. For the acute situation (threatened airway or visual field), IV steroid can be given. With steroids, 30% regress, 40% stabilize, 30% do not respond.
For those that fail steroid therapy, interferon alfa-2a is another option. The response is slower than seen with steroids, yet it accelerates regression in most instances, requiring 6-12 months of sustained therapy. It has lowered the mortality of intrahepatic hemangiomas and has been used successfully in tumors with Kasabach-Merritt phenomenon.
Laser therapy has been advocated for early use in nascent hemangiomas. However, the superficial hemangiomas that respond the best are also the very tumors that do not cause acute problems and regress in time, leaving normal skin. Carbon dioxide laser excision can reopen the airway blocked by a localized subglottic hemangioma.
Surgery in infancy is indicated for certain localized or pedunculated hemangiomas, particularly if they are ulcerated or bleed repeatedly. It also may be necessary to surgically debulk a tumor (upper eyelid) that is failing to respond to pharmacologic therapy.