Localized dystrophic periocular calcification: a complication of intralesional corticosteroid therapy for infantile periocular hemangiomas

Giant pilomatricoma (pilomatrixoma) following an intramuscular injection

We describe a young Indian male patient who developed a large solitary tumor following an intramuscular injection at the same location. The tumor was histologically proven to be a pilomatricoma. It was treated by surgical excision and there was no recurrence until one year after the operation. An alarming phenomenon following intramuscular injection is presented here for its novelty.

Dystrophic calcification in the epidural and extraforaminal space caused by repetitive triamcinolone acetonide injections

The authors report a case of epidural and extraforaminal calcification caused by repetitive triamcinolone acetonide injections. A 66-year-old woman was admitted presenting with lower extremity weakness and radiating pain in her left leg. Ten months before admission, the patient was diagnosed as having an L4-5 spinal stenosis and underwent anterior lumbar interbody fusion followed by posterior fixation. Her symptoms had been sustained and she did not respond to transforaminal steroid injections. Repetitive injections (10 times) had been performed on the L4-5 level for six months. She had been taking bisphosphonate as an antiresorptive agent for ten months after surgery. Calcification in the ventral epidural and extraforaminal space was detected. The gritty particles were removed during decompressive surgery and these were proven to be a dystrophic calcification. The patient recovered from weakness and radiating leg pain. Repetitive triamcinolone acetonide injections after discectomy may be the cause of dystrophic calcification not only in the degenerated residual disc, but also in the posterior longitudinal ligament. Possible mechanisms may include the toxicity of preservatives and the insolubility of triamcinolone acetonide. We should consider that repetitive triamcinolone injections in the postdisectomy state may cause intraspinal ossification and calcification.

Treatment of hemangiomas of infancy

Hemangiomas of infancy are the most common tumors of childhood. They are clinically heterogeneous and as such require individualized treatment plans. Although there are no Food and Drug Administration (FDA)-approved agents for treatment of hemangiomas of infancy, there are many widely used therapeutic options available. This review highlights the treatments currently in use and the factors that direct treatment.

Corticosteroid treatment of periorbital haemangioma of infancy: a review of the evidence

AIM

To systematically review the literature for corticosteroid treatment of periorbital haemangioma of infancy (HOI) and determine the relative efficacy and safety of oral, topical and intralesional corticosteroids.

METHODS

PubMed and the Cochrane Library were queried using keywords, and further articles were obtained by reviewing bibliographies. Inclusion and exclusion criteria were applied to create a subset of literature for analysis.

RESULTS

Systematic review revealed 81 original reports of periorbital HOI cases treated with steroids. Most studies and case series failed to document refractive error or visual acuity before and after treatment. Of cases meeting inclusion criteria, five patients received topical steroids and 25 patients received intralesional steroids. Patients receiving intralesional injections tended to demonstrate reduced astigmatism at follow up after treatment (21 of 28). The lack of studies with relevant objective ophthalmological end points prevented statistical meta-analysis.

CONCLUSION

Intralesional injections may reduce refractive error, while the efficacy of topical steroids is unclear. Studies measuring objective ophthalmic data before and after treatment are sparse, and more studies are needed to determine the relative efficacy of different steroids. There are insufficient data to estimate the incidence of steroid side effects in patients treated with steroids for periorbital HOI or complications of intralesional injections in particular.

Periocular hemangiomas: what every physician should know

Hemangiomas are the most common benign tumor of infancy. Most hemangiomas remain asymptomatic and can be managed by close observation; however, immediate treatment is indicated for hemangiomas that may cause significant complications. Periocular hemangiomas warrant close evaluation and early, active treatment of those with the potential to threaten or permanently compromise vision. Herein we review the clinical features of periocular hemangiomas, differential diagnosis, possible ophthalmologic complications and sequelae, and therapeutic modalities.

Ophthalmic Issues in Hemangiomas of Infancy

Hemangiomas are the most common benign tumor of infancy. Although most hemangiomas remain asymptomatic, certain hemangiomas can cause significant morbidity and require treatment. Periocular hemangiomas require close observation and early therapy for those lesions with potential for visual impairment. Hemangiomas typically cause visual morbidity by induction of amblyopia, strabismus, significant refractive error or optic nerve compromise. Diagnosis is typically straightforward but occasionally other entities may cause diagnostic confusion and radiologic evaluation can be helpful. This is particularly important if the hemangioma is one component of the PHACES syndrome. Therapeutic options which may be useful include steroids (oral, intralesional or topical), interferon alpha (usually reserved for life- or sight-threatening lesions due to serious potential side effects), laser, embolization and surgery. Ophthalmic treatment using patching, atropine, glasses and stabismus surgery may be necessary.

Ulcerated hemangiomas: Clinical characteristics and response to therapy

BACKGROUND

Hemangiomas represent the most common benign tumor of infancy, with ulceration its most frequent complication.

OBJECTIVE

Our purpose was to review our experience with this challenging problem by evaluating the clinical features, management, and therapeutic responses of ulcerated hemangiomas.

METHODS

A retrospective analysis of ulcerated hemangiomas at the University of California, San Francisco outpatient pediatric dermatology clinics and Oakland Children's Hospital from 1987 to 1997 was performed.

RESULTS

The medical records of 60 patients were examined. Forty-nine female and 11 male patients were seen with a female/male ratio of 4.5:1. The majority of ulcerated hemangiomas were of the plaque type (n = 50; 83%) and relatively large; 47 (78%) were larger than 6 cm(2). The perineum was the single most frequently involved site, affected in 20 cases (33%). Topical antibiotics, barrier creams, and bio-occlusive dressings were used in most cases. Systemic antibiotics were used in 26 cases (43%) for overt or presumed infection. Systemic corticosteroids were used in 21 children (37%), 5 of whom did not show a response. Intralesional triamcinolone was used in 7 cases (12%), with 4 showing definite improvement. The flashlamp pulsed-dye laser was the modality used in 22 children (37%), 11 (50%) of whom showed definite improvement, 4 (18%) who showed no significant response, and 1 (5%) who showed definite worsening. Interferon alfa-2a was required in 5 patients (8%), all of whom showed improvement without appreciable neurologic side effects. Immediate surgical excision was required in only 2 cases (3%). Pain control with oral acetaminophen, acetaminophen with codeine, and topical 2.5% lidocaine ointment was effective in managing the pain of lip and perineal hemangiomas, with no side effects noted.

CONCLUSION

No one uniformly effective treatment modality was found, and frequently several were used concurrently. The decision to use specific therapies was dependent on the age of the patient, as well as the location, size, and stage of growth or involution of the hemangioma. Our approach to management included 4 major areas: local wound care, management of infection, specific therapeutic modalities (systemic and intralesional corticosteroids, flashlamp pulsed-dye laser, and interferon alfa-2a), and pain management.

New clinical observations in hemangiomas

Much research in endothelial biology is aimed at developing methods to stimulate productive angiogenesis or inhibit unwanted angiogeneseis. Hemangiomas provide a model for endothelial proliferation and involution. This article is intended to update the reader with new information regarding hemangiomas of infancy, the most common tumor of childhood. Topics such as possible origin, management issues, and psychosocial stresses are addressed. This field is constantly changing, but an effort has been made to include most of the recently reported articles. Our hope is that this information will enable physicians caring for patients with hemangiomas to better address the concerns of their patients and families.