On this episode I welcome Shivani Patel, MD, FAA, Board Certified Dermatologist and Board Certified Pediatric Dermatologist. Find her on Instagram @Pedsdermdoc.

We discuss the following and so much more:

• What exactly a hemangioma is
• Hemangiomas in children
• General management and when to see a dermatologist
• Management options – monitoring vs. therapy
• When a hemangioma may become medically concerning

00;00;08;24 – 00;00;26;06

Dr. Mona

Welcome to this week’s episode where I welcome back Doctor Shivani Patel. She is a board certified pediatric dermatologist. On Instagram, as per stormed off and she is joining me to talk about hemangioma today. Thank you for joining me today. Doctor Patel.

 

00;00;26;08 – 00;00;28;05

Shivani Patel

Thank you for having me back.

 

00;00;28;07 – 00;00;47;15

Dr. Mona

Well, you’re on my episode about eczema, episode 79, and it was such a great conversation. So I’m so glad that you could come back on the podcast to talk about a topic that I also get a lot of questions about. And as general pediatricians, although we diagnose and can talk to families about hemangiomas, we’re not the ones doing the heavy management.

 

00;00;47;15 – 00;00;58;27

Dr. Mona

If a child needs any intervention. So I’m so glad we could talk together about hemangioma in general, what the management is, if there is therapy that’s needed. So thank you again.

 

00;00;59;00 – 00;01;07;04

Shivani Patel

Absolutely. Thanks for having me on again. I think this is a really good topic to go over and it’s very common. So it’s nice to sort of have that information out there.

 

00;01;07;06 – 00;01;12;15

Dr. Mona

And tell me a bit more about yourself. And why you chose to be a pediatric dermatologist.

 

00;01;12;17 – 00;01;45;03

Shivani Patel

Yeah. So, I, like you said, pediatric dermatologist, we are a special group of dermatologists where we completed our residency in dermatology and then do a one year fellowship where we really focus just on dermatologic needs of pediatric patients. And it’s an area that I really enjoy doing because I just, enjoy communicating with the whole family, sort of getting to know the whole family unit, taking care of a child, answering the questions of parents who, you know, maybe nervous or anxious about a diagnosis and being able to sort of guide them to the right treatment.

 

00;01;45;06 – 00;02;01;21

Dr. Mona

And like I said, I’m just so glad that we connected on social media. If you have not already, you have to listen to episode 79 about eczema. We really get into so much information. Even if your child doesn’t have eczema. It is just such good education and I know this is going to be a great conversation as well.

 

00;02;01;23 – 00;02;13;11

Dr. Mona

And we’re talking about him. Angie Omas many people listening may not know what a hemangioma is. So do you mind explaining what it is, what you know, describe? Maybe. I know it’s a podcast, but what it would look like.

 

00;02;13;14 – 00;02;31;24

Shivani Patel

Sure. So, I mean, Joma has a couple different name, so you can either hear it as an infantile hemangioma, a hemangioma, or even a strawberry birthmark because they kind of look like little strawberries on the skin. And these are birthmarks composed of blood vessels that are just on the surface of the skin. And, they’re very, very common.

 

00;02;31;24 – 00;02;49;19

Shivani Patel

Like I said, they happen in about one inch 20 infants. So very common. And they form when blood vessels multiply more than they should. And they usually look like a red bump on your baby’s skin. But some hemangioma can actually look a little more blue or purple, and then even some can be a little bit skin colored.

 

00;02;49;22 – 00;03;11;20

Shivani Patel

And the way that you can sort of know the difference and why there’s different colors is, there’s three different types of hemangioma. You have either a superficial type, a mixed type or a deep type. And my mentor taught me this amazing analogy that I like to use with families. And so what I’ll have you do is just imagine an iceberg in the ocean, and you can either see the entire iceberg on the surface of the water.

 

00;03;11;23 – 00;03;28;22

Shivani Patel

You can either see some of it on the surface and part of it underneath, or the entire iceberg that’s underneath the ocean. And that is exactly how we classify hemangioma. So the superficial types, those are like those icebergs that are all on the surface of the water. So they are right on the surface of the skin. They’re bright red.

 

00;03;28;24 – 00;03;46;25

Shivani Patel

And they usually have this sort of again strawberry or bright look to them. Mixed hemangioma. Those are like those icebergs where you have parts that are under the water and over the water. So some of it is a little bit on the surface of skin, a little bit is deeper. And so because of that they tend to look more purple or blue instead of that bright red.

 

00;03;46;27 – 00;04;01;16

Shivani Patel

And then you have deeper on Mars. And those are like those icebergs that are fully under the water. So really none of it is on that surface of the skin. It’s all very deep. And so the color doesn’t really radiate to the skin. So they can actually look more like your child’s skin color, but just look more like a bump.

 

00;04;01;19 – 00;04;14;24

Dr. Mona

Oh, I love that analogy. Don’t you love when you have a mentor that teaches you something that carries with you for the rest of your career, and you never you’ll never forget it. You’ll always be able to explain it back to someone else. So that is awesome. I haven’t heard that one, and I just think it’s such a great way to describe it.

 

00;04;14;26 – 00;04;24;09

Dr. Mona

And how young can we see him and Yeomans and children? Because sometimes, obviously they’re at birth. So, when can they develop as it is? Very. What is the timing of it?

 

00;04;24;11 – 00;04;44;01

Shivani Patel

Yeah. So most, hemangioma will actually appear after 2 to 3 weeks of life, very rarely they’ll be present at birth, but most of the time the majority, they won’t be there at birth. And then parents will notice that after you brought your baby home and then a few weeks later, you start to notice this sort of red dot, or maybe like a blue purple tone to a part of the skin.

 

00;04;44;01 – 00;05;01;11

Shivani Patel

And that’s when they start to be noticed. And what happens after that point is, they kind of follow the same course most of the time where they have what’s called a growth phase up until about five months of age. And that is when that hemangioma starts to grow. And so it looks like it did when you first notice it.

 

00;05;01;11 – 00;05;19;28

Shivani Patel

And then it starts to double in size or get wider, or get more bright red, or start to change in its shape or appearance. By age three, most of us have reached about 80% of their size. So it happens very quickly in the newborn period. And then after those first five months, they stabilize. So they don’t really change much.

 

00;05;19;28 – 00;05;38;25

Shivani Patel

They kind of just stay like they are and then starting around your baby’s first birthday, you may start to see them shrink, so they’ll start to get smaller, or they’ll start to get a little more gray, which means they’re starting to go away. And then you’ll start to see them sort of resort back. And so most of that shrinking happens by your child’s fourth birthday.

 

00;05;38;28 – 00;05;56;25

Shivani Patel

And so even though we counsel parents that, oh, they go away 100% of the time, they actually don’t. They nearly half the time they can leave a little bit of scar tissue or extra fat tissue or some blood vessels on the skin, but majority of the time it’s very subtle. So usually they don’t even know they’ve had one unless their parent pointed out to them.

 

00;05;56;25 – 00;06;13;08

Shivani Patel

And this is why we don’t see a lot of adults walking around on the streets with the. And almost because, you know, if one inch 20 kids have it, you’d expect more of us to sort of see them. But most of the time they go away. And even if they do leave something behind, it’s so subtle that it tends to not be something that people even notice or need treatment for.

 

00;06;13;11 – 00;06;28;21

Dr. Mona

And knowing that so many of them do go away on their own. What is the general management for them? When do they, you know, need to be referred to a dermatologist? Is it also something like personal preference for the parent, or are there certain things about the hemangioma that would need a referral?

 

00;06;28;23 – 00;06;56;19

Shivani Patel

Yeah, sometimes there is a personal preference. I know some parents just want that sort of second opinion and just sort of, make sure something can place eyes on it, which I think is very reasonable. But in the majority of cases, hemangioma don’t really need treatment and they tend to not be referred. So we don’t even see the majority of them, I think, in our clinics, because they can be managed and just watched by, your child’s pediatrician and imagine ones that are usually very small, you know, less than 1 or 2cm, that are on non cosmetic areas of the skin usually don’t need treatment.

 

00;06;56;19 – 00;07;16;02

Shivani Patel

And non cosmetic areas are areas that usually aren’t seen by others. And so they’re easily hidden by clothing like the back or the chest or the upper thighs. The abdomen. That’s the majority of our body surface area. So most of them that occur in those areas, they really don’t need treatment. Because even if it does leave something behind, a little bit of residual tissue, it’s going to be covered by clothing.

 

00;07;16;02 – 00;07;48;16

Shivani Patel

The majority of your life that people aren’t really going to see it. We tend to just watch those and see how they go away on their own. But they tend to need referral when they’re in cosmetically sensitive areas or areas that can impact function. So areas like the face, for example, or if you have a hemangioma that goes down an entire arm that could impact movement or grip, a hemangioma that is, for example, on the lip, where the infant now has an issue with latching or feeding, an hemangioma on the eyelid that can sort of droop the eyelid and then cause the child to have lazy eye.

 

00;07;48;17 – 00;08;04;15

Shivani Patel

These are some of the areas where they absolutely need that referral. And so command dramas like this that, again, are in those cosmetically sensitive areas or areas that could impair the function of that body part, are the ones that tend to get referred to us and the ones that need treatment.

 

00;08;04;18 – 00;08;17;11

Dr. Mona

And in terms of therapy options or treatment. So just say it is in a cosmetic area, you know, what are some options for treatment? I know this is a rarity that it can happen. But I would love if you can kind of go over like the main popular ones.

 

00;08;17;13 – 00;08;40;01

Shivani Patel

Yeah. So the absolute standard, first line now in these sort of cosmetically sensitive areas is a medication called propranolol. This medicine was actually FDA approved in 2014, and we’ve been using it ever since. And it’s kind of tossed everything else out to the side because it works so incredibly well. And it’s an oral medicine that it’s a liquid that you give to your child twice a day.

 

00;08;40;03 – 00;08;59;29

Shivani Patel

And parents can notice rapid shrinking even within the first few days after starting the medicine. So it works extremely quickly, and we usually continue it until usually about the first birthday. And then case by case basis, we can sort of, sort of start to take the baby off the medicine, or maybe leave them on a little bit longer if we feel like they could use a little bit extra of it.

 

00;09;00;03 – 00;09;16;20

Shivani Patel

And this, medicine is actually a blood pressure medication for infants who are born with high blood pressure. And so there is a risk that it could lower blood pressure or lower the heart rate. But we do use this medicine in much lower doses than what is used to control blood pressure. So the risk is is very low.

 

00;09;16;22 – 00;09;37;18

Shivani Patel

We do still monitor heart rate and blood pressure during the treatment just to be extra safe, but it’s very rare that, something like that would happen. And then the other side effect that we often counsel families on is low blood sugar. And this usually only happens in small babies who are less than five weeks old. But as long as you’re giving the medicine with feeds, again, the risk is very low.

 

00;09;37;18 – 00;09;57;15

Shivani Patel

So we always say give it medication with feeds, make sure you’re feeding at the same time. And that helps negate that risk as well. Now propranolol isn’t necessary for all cases. In some there is a a treatment option called Temel, which is actually the topical version of propranolol that you can apply directly onto the hemangioma surface.

 

00;09;57;21 – 00;10;14;13

Shivani Patel

So you don’t have to take the medication by mouth. And it’s nice because it doesn’t have the side effects with the low blood pressure or the low heart rate or the low blood sugar. Because it’s only topically applied and it’s really only dryness or some skin irritation that you may see from it, but it doesn’t work as well.

 

00;10;14;13 – 00;10;33;01

Shivani Patel

So we won’t use this in cases that really can impair function and emergent cases. But if there’s one on a case by case basis, maybe a larger one on the back or something that’s maybe a little bit bigger on the chest, sometimes we’ll use Temel instead, and see if that helps. And then if not, we can always go to the oral medication if we need to.

 

00;10;33;03 – 00;10;51;01

Dr. Mona

This episode is brought to you by the New Moms Survival Guide, an online digital course and community brought to you by me, Doctor Mona Ameen. Join me as I guide you through your first year of motherhood. This course is not just a how to for your baby, but a how do you get through the ups and downs of motherhood.

 

00;10;51;03 – 00;11;10;29

Dr. Mona

From my experience as a board certified pediatrician and mom, I share the foundations of parenting, newborn feeding, sleep, introduction to solids, infant behavior and development, and so much more. I educate and empower you so that you can be the best mother for your baby. Visit PS doc com for more information and to sign up today.

 

00;11;11;01 – 00;11;28;16

Shivani Patel

Sometimes we’ll use laser therapy or surgical removal. These were done a lot more often before propranolol was around, and we still use them for human judgment. But we tend to wait because most of them go away on their own. We don’t want to put a child through surgery and leave them with a scar, or put them through laser if it’s going to just resolve on its own.

 

00;11;28;16 – 00;11;49;28

Shivani Patel

So we’ll often wait till they’re elementary school age. And at that point, if a lot of it hasn’t gone away, then we know it probably won’t by then. And then they could be a good candidate for that too. But the main thing to really know about these treatments, and especially the propranolol, is that it is so critical that babies are seen as early as they can, usually within the first 2 to 3 months of life.

 

00;11;50;00 – 00;12;06;23

Shivani Patel

Treatment usually works best. When it started early and like I mentioned, that rapid growth phase is really what you’re trying to stop. So if that Amanda has already grown and it’s already, you know, destroyed the nasal cartilage or destroyed the eyelid, and then we try to start the medicine, it’s already done the damage and it’s very hard to reverse it.

 

00;12;06;23 – 00;12;24;01

Shivani Patel

So I always encourage pediatricians in the area as well. Send them early, even if you’re not sure. It’s better to just be safe and sort of get them in right away. Because if we can start treatment starting early has the best chance to make them stop growing and make them go away faster.

 

00;12;24;04 – 00;12;45;08

Dr. Mona

And is there any time when hemangioma has become medically concerning? I know we’re talking about, you know, cosmetic, which I think is really important that people here are that doing something for cosmetic reasons is okay. I think there’s also some families sometimes like, well, if it’s cosmetic, I’m like, no, like this is something that there’s options for. I don’t want us to feel bad about wanting to do something for cosmetic reasons.

 

00;12;45;08 – 00;12;58;14

Dr. Mona

I mean, it’s important to recognize that this is something that we should we can do, and it’s it can really be beneficial. But is there any time that I’ve manji on my meaning, like on the location of the body, number of mango moles, etc. can be medically concerning?

 

00;12;58;17 – 00;13;20;15

Shivani Patel

Yeah. So, I agree with that whole cosmetic point you brought up as well. Just, you know, just to kind of reiterate that I think a lot of parents sometimes feel guilty, but, you know, kids are mean. Kids do tease kids as well. And it is nice to have an option, for your child, you know, thinking, what are they going to feel like when they’re 15 or 20 or 30, you know, and their nose isn’t symmetrical anymore?

 

00;13;20;15 – 00;13;37;25

Shivani Patel

Or, you know, they have a bump in their lip or a bump on their eye. So those are things that we often have to consider. And then of course, when it’s medically life threatening, it’s really no option but the propranolol and we really have to do it. And those were cases, for example, like command gel that occur along the jawline or the chin.

 

00;13;37;27 – 00;13;58;02

Shivani Patel

And it’s what we call the beard distribution. So a hemangioma that occurs sort of in the beard area, they can extend into the airway and actually hemorrhage or obstruct the airway. So that is an absolute sort of life threatening emergency. We have to have them coordinated with the pediatric ENT or otolaryngology doctor. They have to scope the child, make sure that they don’t see any hemangioma there.

 

00;13;58;04 – 00;14;23;01

Shivani Patel

And if there is a home in Goma, it needs propranolol right away. And then, even though hemangioma and I are cosmetic, they can actually be medically concerning because you can truly lose vision and a full eye if you don’t have it treated. And I’ve seen that in cases where it just didn’t get treated early enough, where it just gets to the point where it can totally sort of drop that lid down, impact vision in that eye, which can be really detrimental.

 

00;14;23;04 – 00;14;44;13

Shivani Patel

And then, an injury almost on the face that are greater than five centimeters, they can have a risk of a syndrome called face. And this is where babies can actually have not only a hemangioma, but abnormal vessels in the brain and abnormal heart vessels. And so these babies need very urgent cardiac workup. They need an MRI of the head and the neck.

 

00;14;44;13 – 00;15;03;12

Shivani Patel

They need an ultrasound of the heart. They need to have further workup to make sure that there’s nothing else life threatening medically or even in the brain that could cause other issues. And then lastly, like you were saying, the number of hemangioma, if you have a baby with greater than five hemangioma, is there is a risk that you could have a hemangioma in the liver.

 

00;15;03;12 – 00;15;14;29

Shivani Patel

And so these babies do need a liver ultrasound. And then if there is a large hemangioma on the liver, oftentimes propranolol can also be used in those cases to prevent hemorrhage or something into the liver as well.

 

00;15;15;01 – 00;15;29;03

Dr. Mona

This was such good information. Again, I’m so happy that we were able to talk about this, because one about the misconception or that guilt when a family does want to get their hemangioma, for their child, therapy for it, they feel like, well, I don’t want to I think it’s so important that we clear that up.

 

00;15;29;09 – 00;15;57;17

Dr. Mona

And then I love your iceberg, your, iceberg analogy just to kind of describe it. So helpful. And like we talked about, like, you know, as a general pediatrician, we diagnose a lot of them and I rarely have to refer. And what you mentioned is really when I do refer, like you said, certain locations definitely immediate refer to EMT like with, you know, obviously for anything related to the throat and then also, you know, if for cosmetic reasons or if a family just wants to have that second opinion.

 

00;15;57;17 – 00;16;04;02

Dr. Mona

So this was such a great episode. What would be your final message for everyone listening today?

 

00;16;04;05 – 00;16;26;17

Shivani Patel

So I’m Angela are actually one of my favorite diagnoses. And I think it’s because it’s so gratifying to see how far we’ve come in treatment. And we actually have a treatment now that works incredibly well. It’s so safe and it’s easy to dose. And this is really one of the few areas in dermatology where we have such an incredible option for treatment that is sustained and can make a huge impact on a baby’s quality of life in the future.

 

00;16;26;19 – 00;16;48;16

Shivani Patel

We used to have to treat these babies with large hemangioma with chemotherapy long term. Still, it’s they would get so many other problems, they would have so many side effects. And since 2014, having this option has been truly life changing. And it’s been a game changer in our field because we can now reassure families that we will be able to treat their hemangioma and give them an outcome that everybody’s happy with.

 

00;16;48;18 – 00;17;04;00

Dr. Mona

Oh, that’s so great. And I love, you know, again, having you on here to hear about all the updates. I know this has been around relatively I mean in the last decade I guess. But it’s just so fun, to know all the advancements that we’ve made to kind of help provide families and children, a better quality of life.

 

00;17;04;00 – 00;17;27;24

Dr. Mona

So thank you again for joining us, Doctor Patel. Remember, everyone you have to follow her at Pedes Derm Doc on Instagram. Listen to our episode about eczema, episode 79 and her Instagram has so much information she is, you know, obviously talking all about skin care. Anything that you have questions about, she’s always, posting. It seems like things that are on your mind.

 

00;17;27;24 – 00;17;33;03

Dr. Mona

So that’s the sign of a good, educator on social media. So thank you again for joining us today.

 

00;17;33;10 – 00;17;34;15

Shivani Patel

Thank you. Thank you for.

 

00;17;34;15 – 00;17;49;23

Dr. Mona

Tuning in for this week’s episode. As always, please leave a review. Share this episode with a friend. Share it on your social media. Make sure to follow me at PedsDocTalk on Instagram and subscribe to my YouTube channel PedsDocTalk TV. We’ll talk to you soon.