Dr. Erin Mathes shared updates in the evaluation and treatment of vascular anomalies, including infantile hemangioma (IH) and port wine birthmarks (PWB).
First, Mathes reviewed the clinical practice guidelines for managing IH. High-risk patients should be referred to a hemangioma specialist. The optimal referral age is 4 weeks. Mathes suggested that clinicians adjust their treatment algorithms to enable earlier evaluation and referral. Evaluation should begin early because there is a window of opportunity for effective treatment. Propranolol is the treatment of choice for problematic IH.
Second, Mathes discussed evaluation and treatment of PWB. Mathes described the connection between PWB and Sturge Weber Syndrome (SWS) and how to evaluate infants at risk of SWS. PWB patterns indicating high risk for SWS include forehead involvement or large surface area involvement that is bilateral with multiple segments. High-risk and/or symptomatic patients should be referred to neurologists and ophthalmologists. Early MR imaging before 3 months of age may be indicated.
Laser treatments can be safe and effective for PWB when performed at less than 1 year of age. Clinicians need to set clear expectations with families, as most PWB will not clear completely with laser treatment. Mathes emphasized that laser treatments are safe and effective in skin of color, with modified laser parameters and timing. For resistant PWB, Mathes suggested trying a different laser, changing laser settings such as pulse duration and spot size, adding topical sirolimus, and taking breaks between treatments. Dermoscopy and dynamic optical coherence tomography can help visualize the size and depth of capillaries in PWB.
Third, Mathes shared evidence for therapeutic options for other vascular anomalies. Lymphatic malformations can be treated with sirolimus or anaplastic lymphoma kinase (ALK) inhibitors in sirolimus-resistant cases. Phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA)-related overgrowth syndrome can be treated with alpelisib.
To conclude, Mathes noted disparities in timely referrals for non-English speaking, publicly insured, and Black patients that can be overcome by supportive systems and good triage.
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