Diagnosis and Management of Infantile Hemangioma

• In two RCTs reporting level of clearance, at least 40 percent of children in laser or
observation arms had complete or near complete clearance of IH (low SOE for lack of
difference between PDL and observation).
• Cohort studies assessed outcomes after CO2 and Nd:YAG (neodymium yttrium
aluminum garnet) lasers and typically reported some resolution of lesion size, but
heterogeneity among studies limits our abilities to draw conclusions (insufficient SOE).
• Harms associated with laser treatment included skin atrophy, bleeding, scarring,
ulceration, purpura, and pigmentation changes. Bleeding and ulceration were observed in
the immediate postoperative period, distinguishing these complications from the possible
natural complications of IH themselves (moderate SOE for association of PDL with
pigmentation changes; low for association with bleeding; and insufficient for scarring.
Low SOE for association of Nd:YAG laser with scarring and insufficient for association
with bleeding and pigmentation changes).
Overview of the Literature
Eleven comparative studies (three RCTs, 210-212 seven retrospective cohort studies, 213-219 and
one prospective comparative study that used treated and untreated lesions and intervention and
control groups 220 ) and 30 case series addressed surgical approaches. The RCTs were conducted
in the Netherlands, 210 Japan, 211 and the UK. 212 Cohort studies were performed in the United
States, 216,217 Greece, 218 Singapore, 213 Russia, 219 and Germany. 214,215 Two RCTs 210,212 compared
PDL to observation; one used traditional PDL in infants aged 1 to 14 weeks, 212 and the second
used PDL with epidermal cooling in infants aged 0 to 6 months. 210 The third RCT 211 compared
the use of non-cooled traditional PDL to longer pulse PDL with epidermal cooling in infants
between 1 and 3 months old. We considered RCTs to be of good 210 and fair quality. 211,212
Cohort studies examined various comparisons between different laser types including PDL
versus Nd:YAG, 215 Argon versus Nd:YAG, 217 short pulse PDL versus longer pulse PDL. 213 One
compared Nd:YAG and CO2 lasers and also included a non-surgical comparison group for
airway IH. 214 Two studies compared different skin cooling protocols with the same laser types,
including Nd:YAG 218 and PDL. 216 One cohort study compared cryosurgery, photothermolysis
with intense pulsed light, and photothermolysis plus sclerosis with alcohol and lidocaine. 219 We
considered two cohort studies as fair quality, 213,218 and the rest as poor. 214-217,219 We considered
the self-controlled comparative study (rated using the Newcastle Ottawa tool) as poor quality. 220
Overall, longer pulse PDL with epidermal cooling was the most commonly used laser for
cutaneous lesions and Nd:YAG was the most commonly used intralesionally. Most studies
reported a higher success rate with longer pulse PDL compared to observation in managing the
size of IH, although the magnitude of effect differed substantially. CO2 laser was used for
subglottic IH in a single study, and was noted to have a higher success rate and lower
complication rate than both Nd:YAG and observation. Studies addressing other surgical
approaches (cryosurgery, intense pulsed light thermolysis) reported some improvements in IH
but included few participants in each arm (total n = 263).
SOE for outcomes after laser and surgical treatments ranged from insufficient to low for
effectiveness outcomes. The evidence was limited by low sample size, and variations in the laser
settings used including wavelength and cooling protocols. For Nd:YAG and CO2 lasers, all
studies were limited by sample size, and SOE was insufficient for all outcome parameters.
Thirty case series reported on harms of surgical approaches for IH (3831 children).
Seventeen case series reported on harms from laser treatments, including 10 studies of PDL, 221-
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