Discussion: Untreated hemangiomas: growth pattern and residual lesions.

I have had a long personal and professional interest in hemangiomas. I not only had two daughters with hemangiomas, but also trained with Dr. Milton Edgerton, who published the first article on steroid treatment of hemangiomas with Dr. Harvey Zarem in 1967.1 Understanding the difficulty parents often have with waiting for hemangiomas to “go away,” my wife and I started a parent support group at Children’s Hospital Los Angeles in 1983. Interacting closely with parents attending the support group taught me three important lesions regarding hemangiomas. First, because of stares, comments, and occasional accusations of child abuse, mothers, more than fathers, bear the brunt of the psychological burden of having a child with a noticeable hemangioma. Public outings and social interactions are affected. Second, I came to realize that girls can be negatively aware of having a birthmark as early as 2 years of age. Boys generally are less aware until older. Finally, I saw that hemangiomas improve significantly with time but often leave some residual physical stigmata. This was especially true of hemangiomas with cutaneous involvement even without a history of ulceration or bleeding. “Untreated Hemangiomas: Growth Patterns and Residual Lesions” is an important and valuable outcome study. It confirms what I have personally observed over my career as a pediatric plastic surgeon. This study gives documentation that should help refute the idea, held by many pediatricians, that hemangiomas go away with time. The article found that the most common hemangiomas referred to plastic surgeons, those with cutaneous involvement, have an almost 75 percent chance of leaving a persistent deformity after involution. The percentage of a residual deformity is much higher in lesions with prior bleeding, ulceration, or infection. These patients were not included in this study. If they had been, the percentage of residual deformity would have been greater. Even in the less common subcutaneous hemangiomas without epidermal involvement, there was a 25 percent likelihood of having residual fibrofatty fullness. Persistent deformity following involution of a hemangioma is a significant issue when approximately half of all hemangiomas are known to occur in the head and neck and when girls are approximately three times as likely as boys to have hemangiomas. A similar anatomical and sex distribution was reported in this article. Although this study looked at hemangiomas that had no treatment, I suspect that similar results would be found in a study that examined residual lesions following treatment of equivalent hemangiomas with laser, steroids, or beta blockers. None of these treatment modalities can restore the normal dermal architecture that never formed in hemangiomas with skin involvement. This article is not perfect. The study is a retrospective investigation and has some small potential for selection bias. In my experience, the end of the involution stage is later than the median 4 years reported in this investigation. However, I believe that the study’s findings are compelling enough that they should be part of any hemangioma discussion so that parents can make an informed decision regarding the expected outcome when hemangiomas are allowed to involute without treatment.