Accurate typing of birthmark will determine treatment course

The method and timing of treatment for vascular birthmarks, which occur in nearly 10% of all infants, depend heavily on accurate typing of the birthmark, according to a speaker at the 69th Annual Meeting of the American Academy of Dermatology.

“There are several different types of birthmarks, so it is important to determine the type of birthmark before considering any possible treatments,” dermatologist Sheila Fallon Friedlander, MD, FAAD, said in a press release. “Most birthmarks pose no risks to infants and are best left untreated, but some can grow and potentially cause complications, particularly if they occur around the eyes, lips, nose or groin area. In addition, any lesion that has the potential to ulcerate should be monitored.”

Infantile hemangiomas

The most common birthmarks are infantile hemangiomas, which appear at birth or shortly thereafter as small strawberry-shaped bumps or flat spots. An infantile hemangioma grows during the first 2 to 6 months of life, and a dermatologist can predict its growth by 3 to 4 months. Most infantile hemangiomas do not pose any health risks, but dermatologists can assess the potential for risk by examining a hemangioma’s location and growth rate in the first few months of life, Friedlander said.

“Over time, most infantile hemangiomas will disappear on their own, but there are instances where dermatologists will recommend treatment,” Friedlander said in the release. “For example, if an infantile hemangioma occurs around the eyes, it can obstruct and prevent normal visual development if left untreated, or, if they occur in the groin area, they can become inflamed and then cause pain to the child. Depending on their size, some facial birthmarks may leave behind a scar or saggy skin after they disappear. That is why it is often important for parents to consult a dermatologist as soon as their baby develops a birthmark, so it can be properly evaluated to determine if treatment is necessary.”

A broad facial hemangioma is sometimes the first sign of a serious disorder, termed PHACE syndrome, which may point to an underlying abnormality, including heart defects, eye abnormalities, blood vessel or brain problems. These hemangiomas require specialized evaluation and imaging, Friedlander said.

There are several treatment options for infantile hemangiomas. Systemic steroids and intralesional steroid therapy, although widely used, may result in adverse effects and must be discussed with parents. A recent breakthrough is the use of the blood pressure-lowering drug propranolol, which has been found to effectively prevent growth and even shrink infantile hemangiomas. Propranolol is also associated with adverse events and must be monitored closely, Friedlander said, adding that topical medications and laser therapy are other treatment options.

Port-wine stains

Port-wine stains are a common type of vascular birthmark that darken and thicken over time and will not resolve on their own. Flat with a pink, red or purplish discoloration, port-wine stains typically appear on the face and can cause emotional suffering. They can also be associated with eye problems, including glaucoma, and seizure disorders, Friedlander said.

“Because port-wine stains grow and thicken over time and will not go away, many parents opt to treat them early when children are small,” Friedlander said in the release “While dermatologists have been using pulsed-dye lasers for decades to treat these types of birthmarks, different forms of laser therapy that penetrate more deeply — such as the Nd:YAG laser and the alexandrite long-pulsed laser — also are now being used with much success.”

Laser therapy is usually started within the first 6 to 12 months of life, and approximately six to eight treatments are needed to obtain optimal results. New research is investigating the use of an oral medication, rapamycin, for treating port-wine stains in conjunction with laser therapy, she said.

White birthmarks are much rarer than red birthmarks and appear as either flat or raised white spots on the skin. Although generally harmless, some can grow to the point of needing removal. In the rare case of removal, excision by CO₂ laser is sometimes used, Friedlander said.

Brown birthmarks carry melanoma risk

Congenital nevus, a brow mole present at birth, results from an increased number of melanocyte cells and has the potential to develop into melanoma. Approximately 3% to 6% of very large congenital nevi can become cancerous, but these rates are debated, Friedlander said. Moles deemed high risk should be monitored closely or considered for surgical removal.

The café au lait birthmark is a light brown flat lesion that does not pose medical concerns unless there are multiple birthmarks or a very large spot is present, Friedlander said.

“If a patient has multiple café au lait birthmarks, they need to be evaluated by a dermatologist for other associated conditions. In particular, the health care provider needs to rule out neurofibromatosis, a genetically inherited disorder in which the nerve tissues grow tumors,” she said in the release. “For patients who want to treat a cosmetically troublesome facial café au lait birthmark, various lasers exist that can be useful.”

For more information:

Friedlander SF. Presented at: 69th Annual American Academy of Dermatology Meeting; Feb. 4-8, 2011; New Orleans.

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