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Ulcerated infantile hemangioma treated with imiquimod

  • Author(s): Mascarenhas, Rosa;
  • Guiote, V;
  • Agro, J;
  • Henrique, M
  • et al.
Main Content

Ulcerated infantile hemangioma treated with imiquimod
Rosa Mascarenhas MD1, V Guiote MD1, J Agro MD2, M Henrique MD1
Dermatology Online Journal 17 (9): 13

1. Department of Dermatology
2. Department of Pediatrics
Hospital de Santo André, Leiria, Portugal


Abstract

A 5-month-old boy was observed in our department presenting with an ulcerated infantile hemangioma on the right buttock. This lesion appeared during the first week of life and had been growing progressively, showing ulceration for 3 weeks. We started treatment with corticosteroids, first with the association of betametasone and fusidic acid topically, and then systemically. After 6 weeks of oral treatment as there was no significant improvement, corticosteroid therapy was slowly tapered and local application of imiquimod 5 percent cream, on alternate days, was started. After 12 weeks of therapy with imiquimod there was complete resolution of the ulceration. There were no side effects.



Introduction

Infantile hemangioma is a common benign vascular tumor of childhood.

In most cases these lesions do not need treatment. However, when they are in sites of risk for functional complications, have considerable size, or repeatedly show bleeding, ulceration, or superinfection, treatment is required [1, 2, 3].

We describe the case of a 5-month-old boy with an ulcerated infantile hemangioma of the buttock that showed a good response to imiquimod.


Case report


Figure 1Figure 2
Figure 1. Nodular-erythematous lesion ulcerated in the center on the right buttock.

Figure 2. The same lesion after 6 weeks of oral corticotherapy.

We observed, in our department, a 5-month-old boy presenting with a nodular-erythematous lesion, ulcerated in the center, on the right buttock (Figure 1). This lesion appeared during the first week of life and had been progressively enlarging, showing ulceration for the last 3 weeks. With the diagnosis of ulcerated infantile hemangioma, we started treatment with topical corticosteroids, along with betametasone and fusidic acid cream. After 2 weeks the ulceration worsened and oral corticotherapy was started (deflazacort corresponding to a dose of 2.5 mg of prednisone). After 6 weeks of oral treatment, as there was no significant improvement (Figure 2), corticosteroid therapy was slowly tapered and local application of imiquimod 5% cream, on alternate days, was started. After 4 weeks of treatment with imiquimod, the lesion was much better (Figure 3).


Figure 3Figure 4
Figure 3. Clinical improvement after 4 weeks of treatment with imiquimod.

Figure 4. Complete resolution of the ulceration after 12 weeks of therapy with imiquimod.

Figure 5
Figure 5. Residual hemangioma.

After 12 weeks of therapy with imiquimod, there was complete resolution of the ulceration (Figure 4) and therapy was stopped.

There were no side effects during the treatment.

After 2 years of follow-up the patient is showing only a small residual plaque (Figure 5).


Discussion

Infantile Hemangioma is a common benign vascular tumor of childhood. These usually do not need treatment. However, when they are localized at sites of risk for functional complications, have considerable size, or repeatedly show bleeding, ulceration, or infection, treatment is needed [1, 2, 3].

Since 2002 imiquimod has been used as an alternative treatment in infantile hemangioma [4]. More than 30 cases have been reported since then [4-9]. Most of them showed complete clearance or considerable improvement. Imiquimod was applied 3 to 7 times per week [4-9].

The authors report this case because of the good response to topical imiquimod.

We make note of the presence of gray areas, suggesting the start of regression, after 6 weeks of systemic corticotherapy. However, they were discreet and improvement continued during corticotherapy tapering and imiquimod treatment. Both corticosteroid therapy and imiquimod contributed to regression, which was faster than would usually be related to natural history.

The authors specially emphasise the fact that imiquimod is a topical treatment usually with no side effects. Should this treatment be considered more often?

References

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3. Pandey A, Gangopadhyay AN, Upadhyay VD. Evaluation and management of infantile hemangioma: an overview. Ostomy Wound Manage. 2008 ;54(5):16-29. [PubMed]

4. Martinez MI, Sanchez-Carpintero I, North PE, et al. Infantile hemangioma: clinical resolution with 5% imiquimod cream. Arch Dermatol, 2002; 138(7):881-4. [PubMed]

5. Welsh O, Olazarán Z, Gómez M , et al. Treatment of infantile hemangiomas with short-term application of imiquimod 5% cream. J Am Acad Dermatol, 2004;51(4):639-42. [PubMed]

6. Hazen PG, Carney JF, Engstro Cw, e tal. Proliferating hemangioma of infancy: successful treatment with topical 5% imiquimod cream. Pediatr Dermatol, 2005; 22(3):254-6. [PubMed]

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8. Czernik A, Bystryn JC. Does imiquimod work in infantile hemangiomas? J Am Acad Dermatol. 2007;57(3):535. [PubMed]

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