Introduction

The Women’s and Pediatric Dermatology Seminar took place September 18–21 at the Grand Hyatt Hotel in San Francisco, California. The conference featured many outstanding speakers, numerous workshops, and several new activities including the Pediatric Dermatology reality and jeopardy shows. This report summarizes some of the conference sessions and emphasizes advances made in the pediatric dermatology field.,

Infantile Hemangiomas: New Discoveries

Infantile hemangiomas are the most common tumor of infancy for which specific patterns and subtypes have been recognized. Infantile hemangiomas can be divided into localized hemangiomas and segmental hemangiomas. Localized hemangiomas are confined spatially and often appear to arise from a central focal point. Segmental hemangiomas include those infantile hemangiomas that involve broader anatomic regions or recognized developmental units. Four key facial segments (frontotemporal, maxillary, mandibular and frontonasal) have been described, after it was recognized that facial segmental hemangiomas tend to follow these characteristic locations that appear to be embryologically pre-determined.¹ Segmental facial infantile hemangiomas may be a harbinger of PHACE syndrome (posterior fossa abnormalities, hemangiomas, arterial cerebrovascular abnormalities, cardiovascular anomalies, and eye abnormalities), and ventral developmental defects such as sternal clefts and/or supraumbilical raphe.^2,3

Dr. Ilona Frieden, Clinical Professor of Dermatology at the University of California in San Francisco (UCSF), reviewed recent advances in the understanding of infantile hemangioma patterns and growth characteristics based on the research of the Hemangioma Investigator Group. Dr. Frieden explained that segmental hemangiomas are important to recognize because they are more likely to experience complications and more likely to receive treatment than localized hemangiomas, even when controlled for size. She pointed out that facial segmental hemangiomas are more likely to receive systemic treatment compared with non-facial, non-segmental infantile hemangiomas, which makes facial segmental hemangiomas a critical subtype for dermatologists and primary care providers to recognize.⁴ New information has become available regarding growth characteristics of infantile hemangiomas. A recent prospective study measuring infantile hemangioma growth determined that 80% of hemangioma growth occurs by three months of age and that the majority (80%) of hemangiomas completed their growth by five months of age.⁵ Despite the fact that infantile hemangioma proliferation occurs early in life, the mean age for referral to a specialist was at five months of age. The implication is that the critical period for hemangioma growth and the window of opportunity for treating high-risk hemangiomas occurs during the first few months of life. Dermatologists must be able to evaluate high-risk patients promptly and should encourage timely referral from colleagues.

Treatment options for infantile hemangiomas were reviewed.   A key point is that infantile hemangiomas are very heterogenous, and that many do not require treatment. The mainstay of treatment for large segmental hemangiomas is prednisone, however a recent case series highlighted propranolol as a possible treatment.^6,7 Dr. Frieden offered a word of caution to those prescribing propranolol, and emphasized the importance of monitoring for side effects such as bradycardia, hypotension, and hypoglycemia. A useful suggestion was to collaborate with pediatric subspecialists such as cardiologists, endocrinologists, and nephrologists who have more experience using propranolol in pediatric patients.

Dr. Frieden also reviewed options for treating ulcerated hemangiomas, including topical wound care with metronidazole gel, vaseline gauze dressings, pulsed dye laser treatments, pain management, and becaplermin gel.⁸ Becaplermin recently received a black box warning due to post-marketing studies performed in adults that revealed an increased mortality rate from cancer in patients receiving three or more prescriptions. Although these findings cannot be generalized to the pediatric population, it is advised that becaplermin be used as a second-line treatment for ulcerated hemangiomas.