OBJECTIVES. Infantile hemangiomas often are inapparent at birth and have a period of rapid growth during early infancy followed by gradual involution. More precise information on growth could help predict short-term outcomes and make decisions about when referral or intervention, if needed, should be initiated. The objective of this study was to describe growth characteristics of infantile hemangioma and compare growth with infantile hemangioma referral patterns.
METHODS. A prospective cohort study involving 7 tertiary care pediatric dermatology practices was conducted. Growth data were available for a subset of 526 infantile hemangiomas in 433 patients from a cohort study of 1096 children. Inclusion criteria were age younger than 18 months at time of enrollment and presence of at least 1 infantile hemangioma. Growth stage and rate were compared with clinical characteristics and timing of referrals.
RESULTS. Eighty percent of hemangioma size was reached during the early proliferative stage at a mean age of 3 months. Differences in growth between hemangioma subtypes included that deep hemangiomas tend to grow later and longer than superficial hemangiomas and that segmental hemangiomas tended to exhibit more continued growth after 3 months of age. The mean age of first visit was 5 months. Factors that predicted need for follow-up included ongoing proliferation, larger size, deep component, and segmental and indeterminate morphologic subtypes.
CONCLUSIONS. Most infantile hemangioma growth occurs before 5 months, yet 5 months was also the mean age at first visit to a specialist. Recognition of growth characteristics and factors that predict the need for follow-up could help aid in clinical decision-making. The first few weeks to months of life are a critical time in hemangioma growth. Infants with hemangiomas need close observation during this period, and those who need specialty care should be referred and seen as early as possible within this critical growth period.
We read with great interest the article published by Chang et al in the August 2008 issue entitled “Growth Characteristics of Infantile Hemangiomas: Implications for Management”. Infantile Hemangiomas (IHs) management may be difficult and often needs a multidisciplinary approach. They vary widely from small growing lessions to large, function- threatening tumors. In this article, the authors find out that most IHs growth occurs before 5 months, yet 5 months was also the mean age at first visit to a specialist. The authors conclude that those IHs needing specialty care should be referred and seen by a specialist as early as possible within this critical growth period. For pediatricians and primary care providers, this information on hemangioma growth and referral patterns is a key factor for its management1,2.
Store-and-forward teledermatology (SFTD) has demonstrated to be an effective, accurate, reliable, and valid approach for the routine management of patient referrals in skin cancer and pigmented lesion clinics2. It has generally demonstrated high levels of concordance in diagnosis and management plans compared with face-to-face consultations3.
A SFTD triage system aimed at the selection of patients with vascular anomalies including IHs was implemented in 2008 at the pediatric dermatology unit of our public university hospital and at ten primary care centers. The facility currently covers a total population of 876.654 inhabitants (83.268 of them 14 years old or younger) from a southern spanish province comprising 5 to 100 kms away from the hospital. Nowadays it has turned into an essential complementary tool for our daily clinical practice. Pediatricians working in those primary care centers received specific formation in vascular anomalies. One of the project objectives was to evaluate if SFTD system for children with IHs could shorten the time of first specialized attention. A total of 121 children born after July 31st 2009 presenting 164 IHs were attended between 1st August 2008 and 31st July 2009. Sixty of those children (81 IHs) were referred by teledermatology. Preliminary results showed that children with IHs referred by teledermatology were first evaluated by a pediatric dermatologist with a mean age of 3,5 months, while those referred to the pediatric dermatology unit by the usual way were first evaluated by the specialist at a mean age of 5,9 months (t-test, p< 0,002).
These preliminary results of an on-going multicenter, longitudinal, descriptive and evaluation study show that SFTD for IHs could be a very useful tool to shorten first specialized attention times and may result in a reduction of complications derived from IHs who need specialty care.
References
1. Chang LC, Haggstrom AN, Drolet BA et al. Growth Characteristics of Infantile Hemangiomas: Implications for Management. Pediatrics 2008; 122: 360-7.
2. Beth A, Drolet MD, Elizabeth A et al. Infantile hemangiomas: an emerging health issue linked to an increased rate of low birth weight infants. J Pediatr 2008; 153: 712-5.
3. Moreno-Ramirez D, Ferrandiz L, Nieto-García A et al. Teledermatology as a filtering system in pigmented lesion clinics. Arch Dermatol 2007;143:479-83.
4. Hsiao J, Oh D. The impact of store-and-forward teledermatology on skin cancer diagnosis and treatment. JAAD 2008; 59: 260-267.
Conflict of Interest:
None declared