Diagnosis and Management of Infantile Hemangioma D

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2015 Diagnosis and Management of Infantile Hemangioma D. H. Darrow

A. K. Greene

A. J. Mancini

A. J. Nopper

T. M. O Northwell Health

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Recommended Citation Darrow D, Greene A, Mancini A, Nopper A, O T. Diagnosis and Management of Infantile Hemangioma. . 2015 Jan 01; 136(4):Article 575 [ p.]. Available from: https://academicworks.medicine.hofstra.edu/articles/575. Free full text article.

This Article is brought to you for free and open access by Donald and Barbara Zucker School of Medicine Academic Works. It has been accepted for inclusion in Journal Articles by an authorized administrator of Donald and Barbara Zucker School of Medicine Academic Works. CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Diagnosis and Management of Infantile Hemangioma: Executive Summary David H. Darrow, MD, DDS, Arin K. Greene, MD, Anthony J. Mancini, MD, Amy J. Nopper, MD, the SECTION ON DERMATOLOGY, SECTION ON OTOLARYNGOLOGY–HEAD & NECK SURGERY, AND SECTION ON PLASTIC SURGERY

INTRODUCTION Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the capacity to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. However, a subset of IHs may be associated with complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary care provider is often called on to decide which lesions should be referred for early consultation with a specialist. This document provides a summary of the guidance contained in the clinical report “Diagnosis and Management of Infantile Hemangioma,” published concurrently in the online version of Pediatrics (Pediatrics. This document is copyrighted and is property of the American 2015;136[4]:e1060–e1104, available at: www.pediatrics.org/content/ Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of 136/4/e1060.full). The report is uniquely based on input from the many Pediatrics. Any conflicts have been resolved through a process specialties involved in the treatment of IH. Its purpose is to update the approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial pediatric community about recent discoveries in IH pathogenesis, clinical involvement in the development of the content of this publication. associations, and treatment and to provide a knowledge base and Clinical reports from the American Academy of Pediatrics benefit from framework for clinical decision-making in the management of IH. expertise and resources of liaisons and internal (American Academy of Pediatrics) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they NOMENCLATURE represent. • Infantile hemangiomas (IHs) are vascular neoplasms characterized by The guidance in this statement does not indicate an exclusive course abnormal proliferation of endothelial cells and aberrant blood vessel of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. architecture. In contrast, vascular malformations are structural anoma-

All clinical reports from the American Academy of Pediatrics lies and inborn errors of vascular morphogenesis. The latter include automatically expire 5 years after publication unless reaffirmed, capillary malformations (port wine stains), venous malformations, revised, or retired at or before that time. lymphatic malformations (formerly known as lymphangiomas or cystic www.pediatrics.org/cgi/doi/10.1542/peds.2015-2482 hygromas), and arteriovenous malformations. DOI: 10.1542/peds.2015-2482 • Congenital hemangiomas are biologically and behaviorally distinct from PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). IHs. They are fully grown at birth and present as 2 varieties: rapidly involuting (RICH) and noninvoluting (NICH). Copyright © 2015 by the American Academy of Pediatrics • Pyogenic granuloma, or lobular capillary hemangioma, is a reactive FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose. proliferative vascular lesion. Although classified with the vascular

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they neoplasms and often misdiagnosed as IH, pyogenic granuloma is distinct have no potential conﬂicts of interest to disclose. in its clinical appearance and behavior.

Downloaded from by guest on February 7, 2017 FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 136, number 4, October 2015 • Lesions diagnosed as “cavernous with enlarged draining veins. In- that does not uniformly hemangiomas” are usually, in fact, voluting IHs reveal fibrofatty proliferate. “ ” deep IHs or venous malformations. stroma, residual ghost vessels, • IHs may also be classified accord- • Kasabach–Merritt phenomenon (a mast cells, and apoptotic bodies. ing to their anatomic configuration: consumptive coagulopathy) is not • Immunohistochemical staining of • Localized (focal) IH: discrete associated with IH but rather with IH is positive for glucose trans- lesions, arise from single focal other vascular neoplasms (kaposi- porter 1 (GLUT1), CD31, CD34, point form hemangioendothelioma and factor VIII–related antigen, and • Segmental IH (Fig 3): larger tufted angioma). others; GLUT1 is the most useful lesions, usually plaque-like, cov- and widely used marker for the diagnosis of IH. ering regions probably de- EPIDEMIOLOGY termined by neuroectodermal • The incidence of IH is estimated at CLINICAL PRESENTATION placodes approximately 5% of infants, and • Indeterminate IH: cannot de- • IHs usually appear before 4 weeks the female/male ratio ranges from finitively be categorized as lo- of age and complete most of their 1.4:1 to 3:1. calized or segmental growth by 5 months of age, al- • • IH risk factors include white race, though the proliferative phase may Multifocal IH: focal lesions oc- prematurity, low birth weight, ad- continue up to 12 months of age. curring at more than 1 anatomic vanced maternal age, multiple gesta- Deep IHs tend to appear later and site; may be a marker for hepatic tion pregnancy, placenta previa, and grow somewhat longer. The in- IH when 5 or more cutaneous preeclampsia. Other risk factors may volution phase usually begins be- lesions are present include in utero diagnostic proce- tween 6 and 12 months of age, and • Segmental IH may be associated dures (chorionic villus sampling and the majority of regression occurs amniocentesis), use of fertility drugs with extracutaneous before 4 years of age. As IHs in- manifestations. or erythropoietin, breech pre- volute, they flatten and shrink, with fi • sentation, and being rst born. fading of their color. A small subset of children with IH present with congenital anomalies • Up to 70% of IHs leave behind re- recognized as clinical associations. PATHOGENESIS AND HISTOPATHOLOGY sidual skin changes, including tel- These include: angiectasia, fibrofatty tissue, • The pathogenesis of IH remains to • PHACE, which is a congenital redundant skin, atrophy, dyspig- be clearly elucidated. Both intrinsic mentation, and scar (especially in vasculopathy with features of factors (such as angiogenic and lesions with history of past Posterior fossa defects, Heman- vasculogenic factors) and extrinsic ulceration). giomas, cerebrovascular Arterial factors (including tissue hypoxia • fi anomalies, Cardiovascular and developmental field dis- Premonitory ndings in early IH anomalies including Coarctation turbances) probably contribute to include localized blanching of skin of the aorta, and Eye anomalies. development of IH. and macular telangiectatic erythema. In PHACE, the IH is large and • Endothelial progenitor cells may • segmental, characteristically lo- develop into IH from clonal expan- During the proliferative phase, IHs fi cated on the face, scalp, or neck. sion, resulting in vasculogenesis; may be classi ed based on their • alternatively, fetal progenitor cells depth, as follows (Fig 1): LUMBAR, which refers to Lower • fi arising from disruption of the pla- Super cial IH: Surface appears body IH and other cutaneous centa during gestation or birth may red, and there is little or no dis- defects, Urogenital anomalies give rise to these tumors. cernible subcutaneous and Ulceration, Myelopathy, Bony component. • A unifying theory suggests that IH deformities, Anorectal malfor- • results from aberrant proliferation Deep IH: Surface appears blue or mations, Arterial anomalies, and fl and differentiation of a pluripotent esh-colored, and the tumor Renal anomalies. The associated progenitor cell, which migrates to resides deep below the skin IHs are usually segmental lum- locations in which growth of surface. bosacral or anogenital lesions. placenta-like tissue is favorable. • Combined IH: both superficial LUMBAR, also described under • Proliferative IHs histologically re- and deep components. the acronyms “SACRAL” and veal well-defined masses of capil- • Abortive (arrested growth, mini- “PELVIS,” may be thought of laries lined by plump endothelial mal growth, nascent) IH (Fig 2) as the “lower half of the body” cells, arranged in lobules, often presents as a telangiectatic patch variant of PHACE.

Downloaded from by guest on February 7, 2017 PEDIATRICS Volume 136, number 4, October 2015 787 IMAGING • Imaging of IH is not usually necessary. • Imaging may be necessary when the diagnosis is uncertain, when evaluation of extent is necessary, when the IH is a possible marker of PHACE or LUMBAR syndrome, or when response to therapy must be monitored. • When imaging of IH is performed, ultrasound is the preferred modality for diagnosis, whereas MRI is better to assess extent of the FIGURE 1 lesion. Cutaneous IHs can be classified based on their depth. A, Superficial IHs are visible only at the skin surface and may be focal (as shown here) or segmental. B, Deep IHs have no surface involvement. C, Mixed,orcompound, IHs have both superficial and deep components. CLINICAL APPROACH TO IH • The indications for intervention for COMPLICATIONS • Auditory impairment IH include: • • A minority of IH (up to 24% re- • Nasal deformities Emergency treatment of potentially life-threatening ferred to pediatric dermatologists) • Congestive heart failure: may complications may develop function-threatening occur with large IHs, as a result or life-threatening complications, of arteriovenous shunting • Urgent treatment of existing or imminent functional impairment, including: • Airway obstruction: risk of air- • pain, or bleeding Ulceration: most common IH way IH increased with facial IH complication, occurring in 16% in the “beard” distribution • Evaluation to identify important of patients in 1 large series; risk structural anomalies potentially • Hypothyroidism: may be associ- factors include larger lesions, associated with IH ated with diffuse hepatic IH; segmental IH, and distribution in caused by excess production of • Elective treatment to reduce the the head, neck, perioral, and type 3 iodothyronine deiodinase likelihood of long-term or per- perineal or perianal locations manent disfigurement • Segmental IHs are much more • Bleeding likely to develop complications • There is no algorithm to determine • Visual impairment: associations (usually ulceration) than localized the most appropriate modality and include ptosis, amblyopia, IH. timing of intervention for a given IH. Factors affecting this choice astigmatism • Facial IHs are complicated more include: • Feeding impairment: most often frequently than nonfacial IHs. • Age of the patient associated with IH on the lips or • in the aerodigestive tract Growth phase of the lesion • Location and size of the lesion • Degree of skin involvement • Severity of complications and urgency of intervention • Potential for adverse psychoso- cial consequences • Parental preference • Physician experience

MANAGEMENT OF ULCERATED IH FIGURE 2 Abortive IHs are macular, telangiectatic patches FIGURE 3 • Treatment recommendations for that have failed to fully proliferate. Segmental IH of the face. ulcerated IH are based largely on

Downloaded from by guest on February 7, 2017 788 FROM THE AMERICAN ACADEMY OF PEDIATRICS expert opinion; high-quality studies treatment of IH showed effec- Rebound growth after discontin- of interventions and evidence- tiveness when dosed at 3.4 mg/ uation of therapy is reported in based guidelines are lacking. kg per day for 6 months. 5% to 25% of patients; therefore, • Ulcerated IH management is fo- • Contraindications to propranolol some clinicians wean pro- cused on wound care, pain control, therapy include cardiogenic pranolol over a number of weeks controlling IH growth, and pre- shock, sinus bradycardia, hypo- or months. vention and treatment of secondary tension, heart block greater than • Common adverse effects of pro- infection. Vigilant wound care and first degree, heart failure, asthma pranolol include sleep distur- use of barrier ointments or dress- or reactive airway disease, and bance, cold hands and feet, ings, as well as topical antibiotics, known hypersensitivity to the diarrhea, and bronchial hyperre- are generally considered first-line drug. Special precautions have activity. Rare adverse effects in- therapy for ulcerated IH. been suggested for children with clude bradycardia and • For ulcerated IH with suboptimal PHACE syndrome who have hypotension, which are generally response to conservative topical high-risk intracranial vascular asymptomatic, and severe hypo- care, additional medical or surgical anomalies. glycemia, which may be associ- interventions may be needed. • Recommendations for pre- ated with decreased There is growing evidence that treatment assessment and the responsiveness or seizures. propranolol may be effective in optimal setting for therapy initi- • Precautions that may reduce the treating severe ulcerated IH. In ation continue to evolve and vary risk of hypoglycemia with pro- addition, pulsed-dye laser may also between clinicians. A complete pranolol therapy include admin- be helpful in treating persistent history and physical examination istration of medication after ulceration. Rarely, surgical in- with special attention to the feeding; holding doses when the tervention may be indicated in re- cardiac and pulmonary systems patient is ill with decreased oral calcitrant ulcerations. aids in assessing a child’s candidacy intake, vomiting, or diarrhea; and for propranolol initiation. avoiding prolonged intervals of MEDICAL THERAPY FOR IH Although some clinicians obtain longer than 6 hours between • Systemic corticosteroids were the pretreatment electrocardiogram feedings. mainstay of therapy from the or cardiology consultation before • A number of case reports and 1960s until a 2008 report of starting propranolol, the value of case series have reported suc- serendipitous improvement of IH such screening in patients with cessful use of topical timolol, a b- in infants treated with b-blocker an unremarkable cardiac history blocker used to treat glaucoma, therapy (propranolol). and examination is uncertain. in the treatment of un- fi • b-blocker therapy: • A consensus report recommends complicated super cial IH. Ti- • The mechanism of action of pro- initiation of propranolol therapy in molol 0.5% gel-forming solution pranolol, a nonselective blocker a clinic setting with cardiovascular has less systemic absorption of b-adrenergic receptors that monitoring hourly for 2 hours than timolol in solution. has been used to treat cardiac after initiation and recommends • Corticosteroid therapy: disorders, is not fully un- repeat monitoring for dosage • For patients with contra- derstood. Proposed mechanisms increases of .0.5 mg/kg per day indications or inadequate re- of action include vasoconstric- for infants .8 weeks of age. In- sponse to propranolol therapy, tion, inhibition of angiogenesis, patient initiation of propranolol is corticosteroids may be an effec- downregulation of matrix metal- considered for infants ,8weeks tive treatment alternative. Most loproteinases and interleukin-6, of age or infants with post- studies support dosing with oral regulation of the renin–angio- conceptual age ,48 weeks and for prednisolone or prednisone at 2 tensin system, and inhibition of infants with decreased social sup- to 3 mg/kg per day given in nitric oxide production. port or increased risk factors. a single morning dose. Several • An oral formulation of pro- • Recommended administration of months of therapy is generally pranolol (Hemangeol [Pierre propranolol is 1 to 3.4 mg/kg per necessary; treatment is more Fabre, Castres, France]) for day divided into 2 or 3 doses. likely to be successful when ini- treatment of IH received ap- Duration of therapy is usually tiated during IH proliferation. proval from the US Food and until 8 to 12 months of age, or • Long-term corticosteroid therapy Drug Administration in March between 3 and 12 months of may be associated with many 2014. A large 2015 randomized therapy, depending on age of adverse effects, including irrita- controlled trial of Hemangeol in initiation and clinical response. bility, sleep disturbance, gastric

Downloaded from by guest on February 7, 2017 PEDIATRICS Volume 136, number 4, October 2015 789 irritation, hypertension, immu- a component of multimodal subtotal excision often is per- nosuppression, hypothal- therapy. formed intentionally. – – amic pituitary adrenal axis • The pulsed-dye laser is used most • For circular lesions located on the suppression, linear growth de- commonly, because its light is face, the length of the scar can be celeration, and cushingoid facies. preferentially absorbed by minimized by circular excision and These adverse effects are more hemoglobin. purse-string closure. This pro- frequently seen with higher • Some studies suggest that the use cedure also minimizes distortion of doses and prolonged therapy and of the pulsed-dye laser on pro- surrounding structures and may tend to be reversible. Periodic liferating and segmental IHs may require a second stage to convert monitoring for potential toxicity, lead to ulceration. Atrophic scar- a circular scar into a line. especially blood pressure eleva- ring and hypopigmentation are also tion and decreased rate of potential complications of laser use growth, is recommended. in IH. IHs WITH SPECIAL ANATOMIC • Intralesional steroid injections CONCERNS are often effective in treating • IHs involving the eyelids can de- small, bulky, well-localized IH SURGICAL THERAPY FOR IH form the cornea and obstruct the lesions. However, although ad- • Resection of a proliferating IH visual axis, causing astigmatism, verse systemic effects have been generally is not recommended, be- strabismus, or amblyopia. Early reported rarely, intralesional cause younger patients are at evaluation by a pediatric ophthal- steroids may be systemically greater risk of anesthetic morbidity, mologist and early intervention absorbed, especially when given blood loss, and iatrogenic injury may reduce the risk of complica- in larger doses or multiple than those who undergo operative tions and sequelae. injections, and optimal dosing intervention later in childhood. • and safety profile are not well Indications for excising a hemangi- Propranolol has largely supplanted studied. As a result, this modality oma during infancy include failure intralesional steroid injection for is no longer considered first-line of other therapy for a critical IH, treating problematic IHs of the therapy for most IHs. High- a focal lesion in a favorable loca- upper eyelid because the risk of potency topical steroids have tion, or elective surgery leaving blindness from embolization of the been reported as effective in the a scar that would be the same if the retinal artery. However, intrale- fi treatment of small super cial IH, lesion were removed after sional steroids are an alternative although their use is largely be- involution. for refractory lesions. Topical ing replaced by treatment with b • Delaying surgery until after infancy -blockers may be useful for in- topical b-blockers. allows the lesion time to involute, traocular IHs. • Other medical therapies: becoming smaller and less vascular. • IHs of the airway may occur in • b Medications other than -block- Consequently, the procedure is isolation, but patients with large ers and corticosteroids may have safer, and often the patient has cutaneous lesions involving the fi ef cacy in treating IH, but their a shorter scar and a higher likeli- lower face and neck (the so-called utility is limited by their safety hood of a favorable outcome. “beard” distribution) are at greater fi a pro le. Interferon- appeared to However, most IHs do not improve risk. Most lesions are subglottic, be a promising treatment option significantly beyond 4 years of age, and patients so affected can have in the 1980s and early 1990s, and surgery by this age corrects the biphasic stridor and barky cough but studies showing significant deformity before self-esteem and that are often mistaken for croup. neurotoxicity have generally long-term memory are well Operative endoscopy is generally precluded this treatment modal- established. necessary to identify the lesions ity for IH. • Because hemangiomas usually ex- and assess their extent. Symptom- pand the skin, after they are re- atic lesions are generally treated LASER TREATMENT OF IH moved the wound usually can be with propranolol, but patients who • Laser treatment of IH may be use- reconstructed by linear closure. do not respond rapidly may be fl ful in treating early non- Skin grafts and local aps are rarely candidates for dilation, intrale- proliferating superficial lesions, needed. sional corticosteroid injection, or salvaging critical skin, controlling • Because IH is benign, the entire partial resection. Open resection ulceration, and treating persisting lesion does not need to be extir- has become less commonly in- postinvolution telangiectasia. Laser pated. The goal is to improve the dicated since introduction of pro- therapy may also be used as appearance of the child, and pranolol therapy for IH.

Downloaded from by guest on February 7, 2017 790 FROM THE AMERICAN ACADEMY OF PEDIATRICS • Early management of nasal tip IH hemangiomas and often coexist Jonathan A. Perkins, DO (Otolaryngology) using some combination of phar- with cutaneous lesions. Symp- Michael L. Smith, MD, FAAP (Dermatology) Patricia A. Treadwell, MD, FAAP (Dermatology) tomatic multifocal and diffuse macotherapy and laser reduces the Milton Waner, MD (Otolaryngology, Facial Plastic likelihood of long-term deformity lesions can be treated with sys- Surgery) from skin expansion and atrophy temic pharmacotherapy. Albert C. Yan, MD, FAAP (Dermatology) and of injury to the underlying • Infants with significant multifo- cartilage. Reconstruction of in- cal or diffuse hemangiomas SECTION ON DERMATOLOGY EXECUTIVE voluted nasal tip IHs is often nec- should undergo thyroid hormone COMMITTEE, 2014–2015 essary even with aggressive early screening because the tumor can Bernard A. Cohen, MD, FAAP, Chairperson intervention and includes excision deactivate thyroid hormone. Richard J. Antaya, MD, FAAD, FAAP of the lesion, reconstruction of the Hormone replacement may be Anna L. Bruckner, MD, FAAP cartilaginous framework, and exci- Kim Horii, MD, FAAP necessary. Nanette B. Silverberg, MD, FAAP sion and redraping of the skin. • Diffuse lesions may present with Teresa S. Wright, MD, FAAP • IHs involving the lips and peri- hepatomegaly and cause abdom- Albert C. Yan, MD, FAAD, FAAP, Chairperson-Elect Michael L. Smith, MD, FAAP, Ex Officio neum, especially segmental lesions, inal compartment syndrome. have a higher risk of ulceration; early pharmacotherapy may be ef- FORMER SECTION ON DERMATOLOGY EXECUTIVE COMMITTEE MEMBER fective in avoiding this complica- CONCLUSIONS tion. Reduction of friction on Sheila F. Friedlander, MD, FAAP Although many IHs can be observed perineal IHs using topical lubrica- without treatment, others will clearly STAFF tion with or without a barrier benefit from medical or surgical dressing may help prevent Lynn Colegrove, MA intervention. When complications are ulceration. likely or the threshold for SECTION ON OTOLARYNGOLOGY–HEAD AND • IHs located within the vermilion intervention is uncertain, referral to NECK SURGERY EXECUTIVE COMMITTEE, area of the lip can be removed with an experienced specialist or 2014–2015 a transverse mucosal incision, al- a multidisciplinary vascular anomaly Charles Bower, MD, FAAP, Chairperson though some deep lesions are center may be advantageous. It is Christina Baldassari, MD, FAAP best approached through the important for providers of pediatric German Paul Digoy, MD, FAAP – Andrew Hotaling, MD, FAAP vermilion cutaneous border. Bulkier care to keep abreast of advances in IH lesions that cause lengthening of Stacey Ishman, MD, MPH, FAAP management as continued research John McClay, MD, FAAP the lip and those that cross the leads to pathogenesis-directed Diego Preciado, MD, PhD, FAAP – vermilion cutaneous border are best therapeutic options and as the types Kristina Rosbe, MD, FAAP addressed with a wedge excision. of intervention and their use evolve. Scott Schoem, MD, FAAP, Past Chairperson Eversion of the lower lip can be Jeffrey Simons, MD, FAAP corrected by excision of a mucosal LEAD AUTHORS Steven Sobol, MD, FAAP David Walner, MD, FAAP strip, and correction of inversion David H. Darrow, MD, DDS, FAAP may require a lyophilized dermal Arin K. Greene, MD, FAAP STAFF implant or dermal graft. Anthony J. Mancini, MD, FAAP Amy J. Nopper, MD, FAAP Vivian Thorne • The liver is the most common location of visceral hemangiomas: CONTRIBUTING AUTHORS SECTION ON PLASTIC SURGERY EXECUTIVE • Infants with $5 cutaneous COMMITTEE, 2014–2015 Richard J. Antaya, MD, FAAP (Dermatology) hemangiomas are at greater risk Bernard Cohen, MD, FAAP (Dermatology) Peter J. Taub, MD, FAAP, Chairperson of hepatic lesions and are candi- Beth A. Drolet, MD (Dermatology) Stephen B. Baker, MD, FAAP dates for screening by Aaron Fay, MD (Ophthalmology) Arin K. Greene, MD, FAAP ultrasonography. Steven J. Fishman, MD, FAAP (Pediatric Timothy W. King, MD, MPH, FAAP Surgery) Donald R. Mackay, MD, FAAP, Immediate Past • Liver hemangiomas can be focal, Sheila F. Friedlander, MD, FAAP (Dermatology) Chairperson multifocal, or diffuse. Focal Fred E. Ghali, MD, FAAP (Dermatology) Delora L. Mount, MD, FAAP, Chairperson-Elect lesions are actually RICHs that Kimberly A. Horii, MD, FAAP (Dermatology) Jordon Philip Steinberg, MD, FAAP are fully grown at birth and Manish N. Patel, DO (Radiology, Interventional Mark M. Urata, MD, DDS, FAAP, Radiology) Vice Chairperson rapidly involute over the first Denise W. Metry, MD (Dermatology) STAFF year of life. Multifocal and diffuse Paula E. North, MD (Pediatric Pathology) lesions are true infantile Teresa M. O, MD (Otolaryngology) Kathleen Kuk Ozmeral

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Diagnosis and Management of Infantile Hemangioma: Executive Summary David H. Darrow, Arin K. Greene, Anthony J. Mancini, Amy J. Nopper and the SECTION ON DERMATOLOGY, SECTION ON OTOLARYNGOLOGY−HEAD & NECK SURGERY, AND SECTION ON PLASTIC SURGERY Pediatrics 2015;136;786; originally published online September 28, 2015; DOI: 10.1542/peds.2015-2482 Updated Information & including high resolution figures, can be found at: Services /content/136/4/786.full.html Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Dermatology /cgi/collection/dermatology_sub Section on Dermatology /cgi/collection/section_on_dermatology Section on Otolaryngology-Head and Neck Surgery /cgi/collection/section_on_otolaryngology-head_and_neck_s urgery Section on Plastic Surgery /cgi/collection/section_on_plastic_surgery Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: /site/misc/reprints.xhtml

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