1
00:00:00,000 --> 00:00:07,800
Welcome to the Don't Be Rash Pediatric Dermatology Podcast, the owner's manual for your kid's

2
00:00:07,800 --> 00:00:08,800
skin.

3
00:00:08,800 --> 00:00:13,520
I'm your host, Dr. K, board certified pediatric dermatologist and father of two boys.

4
00:00:13,520 --> 00:00:18,520
I'm here to chat with you to promote dermatological education and improve skin health in our children

5
00:00:18,520 --> 00:00:20,040
everywhere.

6
00:00:20,040 --> 00:00:27,720
Let's get started.

7
00:00:27,720 --> 00:00:29,600
Today's show is going to be a twofer.

8
00:00:29,600 --> 00:00:34,160
We're going to try to cover infantile hemangiomas and port-wine birthmarks.

9
00:00:34,160 --> 00:00:39,320
Joining me today as co-host and my very special guest is Dr. Caroline Piggott, renowned pediatric

10
00:00:39,320 --> 00:00:44,280
dermatologist, a mother herself, accomplished figure skater, and one of the coolest people

11
00:00:44,280 --> 00:00:47,800
I've ever had the pleasure of working with and really truly one of my best friends.

12
00:00:47,800 --> 00:00:52,360
Dr. Piggott did her training in general dermatology with me out at the University of California,

13
00:00:52,360 --> 00:00:53,480
San Diego.

14
00:00:53,480 --> 00:00:58,240
We managed to stay together for our clinical fellowship in pediatric dermatology at Rady

15
00:00:58,240 --> 00:01:00,120
Children's Hospital, San Diego.

16
00:01:00,120 --> 00:01:04,040
Dr. Piggott's clearly smarter than me though, because she stayed there and now lives in

17
00:01:04,040 --> 00:01:07,600
La Jolla and works at Scripps, one of the most beautiful places on earth.

18
00:01:07,600 --> 00:01:08,880
Welcome, Dr. Piggott.

19
00:01:08,880 --> 00:01:11,400
Thanks for joining me from across the country.

20
00:01:11,400 --> 00:01:12,400
Good morning.

21
00:01:12,400 --> 00:01:14,920
Thanks so much for having me, Dr. Krakowski.

22
00:01:14,920 --> 00:01:16,960
It's good to see you.

23
00:01:16,960 --> 00:01:17,960
It's been a long time.

24
00:01:17,960 --> 00:01:20,560
We've been wanting to do this for a while now, so I'm so excited.

25
00:01:20,560 --> 00:01:23,800
We finally get to put it to the test.

26
00:01:23,800 --> 00:01:27,160
No, I'm glad to do it.

27
00:01:27,160 --> 00:01:28,360
So Dr. Piggott, let's jump right in.

28
00:01:28,360 --> 00:01:33,800
How do you approach a red birthmark in a child and, ultimately, how do you make that very

29
00:01:33,800 --> 00:01:37,480
specific diagnosis of infantile hemangioma?

30
00:01:37,480 --> 00:01:41,800
The babies present to me usually a couple of weeks of age with their parents who are

31
00:01:41,800 --> 00:01:45,760
usually somewhat-to-very concerned.

32
00:01:45,760 --> 00:01:48,160
The first thing I do is get a little bit of history.

33
00:01:48,160 --> 00:01:52,780
So I ask them, was it there at birth or when did you first notice it?

34
00:01:52,780 --> 00:01:58,360
Because one of the key things about hemangiomas is they present at some point, usually in

35
00:01:58,360 --> 00:01:59,360
the first month of life.

36
00:01:59,360 --> 00:02:04,920
Some of them are actually present at birth, but some of them are completely absent at

37
00:02:04,920 --> 00:02:09,360
birth and present maybe one, two, three, four weeks of life.

38
00:02:09,360 --> 00:02:14,400
And they often start out flat, like a little red mark.

39
00:02:14,400 --> 00:02:19,920
Many parents will say to me they thought it was a bruise or they thought they had pinched

40
00:02:19,920 --> 00:02:24,320
the child or something like that, and then they'll give me a history that it gradually

41
00:02:24,320 --> 00:02:28,040
starts to get a little bit thicker and maybe darker.

42
00:02:28,040 --> 00:02:31,840
Do you see them in any particular anatomic location or they can be all over?

43
00:02:31,840 --> 00:02:35,160
Oh, they can be anywhere, head to toe really.

44
00:02:35,160 --> 00:02:40,400
Sometimes parents won't even notice because it's in the private parts and they don't

45
00:02:40,400 --> 00:02:44,820
really look very carefully or in some babies who are in the hospital, for example, if they're

46
00:02:44,820 --> 00:02:48,240
born prematurely, they might be in the NICU.

47
00:02:48,240 --> 00:02:52,760
Some parents don't even notice them because they're covered by leads or diapers or things

48
00:02:52,760 --> 00:02:53,760
like that at first.

49
00:02:53,760 --> 00:02:54,760
So they can really be anywhere.

50
00:02:54,760 --> 00:02:55,760
Yep.

51
00:02:55,760 --> 00:02:56,760
Up on the scalp.

52
00:02:56,760 --> 00:02:59,800
If you're born with a bushy head of hair, you might not notice it.

53
00:02:59,800 --> 00:03:00,800
Exactly.

54
00:03:00,800 --> 00:03:01,800
Exactly.

55
00:03:01,800 --> 00:03:04,920
Or parents will say, we thought it was just from the electrode on our child or something

56
00:03:04,920 --> 00:03:06,600
like that.

57
00:03:06,600 --> 00:03:10,960
We've been fooled a couple of times with, like you said, ones that are sort of between

58
00:03:10,960 --> 00:03:14,200
the, for lack of a better word, the butt crack.

59
00:03:14,200 --> 00:03:16,600
You don't know what's there.

60
00:03:16,600 --> 00:03:20,760
Either the scrotum and a male child, you might, you could find them.

61
00:03:20,760 --> 00:03:21,960
They can be anywhere really.

62
00:03:21,960 --> 00:03:24,480
So do you see them always by themselves?

63
00:03:24,480 --> 00:03:28,460
Is it an isolated thing or can you see these present in different ways?

64
00:03:28,460 --> 00:03:33,640
So the most common form is when they're solitary and there's just one.

65
00:03:33,640 --> 00:03:35,320
And that's what I see most commonly.

66
00:03:35,320 --> 00:03:41,320
But there are actually cases where you can have multiple hemangiomas.

67
00:03:41,320 --> 00:03:47,000
It's very important to count how many there are because there's a rare condition where

68
00:03:47,000 --> 00:03:52,400
not only do you have hemangiomas on the skin, but also hemangiomas inside the body.

69
00:03:52,400 --> 00:03:55,200
We call it systemic hemangiomatosis.

70
00:03:55,200 --> 00:04:00,320
What I always do is, you know, the parents might not even know that there's other ones.

71
00:04:00,320 --> 00:04:04,640
So what I always do is completely undress the baby and examine them head to toe.

72
00:04:04,640 --> 00:04:06,000
And I actually count them.

73
00:04:06,000 --> 00:04:09,200
The risk of having ones inside your body.

74
00:04:09,200 --> 00:04:14,480
There's no clear consensus, but I would say on average if there's five or more on the

75
00:04:14,480 --> 00:04:19,160
body, the risk of having one inside the body is a little bit higher.

76
00:04:19,160 --> 00:04:23,280
And sometimes if there's five or more, or sometimes even four, because that's close

77
00:04:23,280 --> 00:04:26,240
enough, we do actually imaging.

78
00:04:26,240 --> 00:04:32,080
The most common type of imaging being an ultrasound of the abdomen because the most common area,

79
00:04:32,080 --> 00:04:34,600
if you're going to have one inside the body, is actually the liver.

80
00:04:34,600 --> 00:04:41,520
So an ultrasound is easy to do, no radiation, not harmful for the baby, no sedation needed,

81
00:04:41,520 --> 00:04:45,600
and you can actually do an ultrasound to make sure there's not one in the liver.

82
00:04:45,600 --> 00:04:47,160
And they can see them pretty easily on ultrasound.

83
00:04:47,160 --> 00:04:48,160
Very easily.

84
00:04:48,160 --> 00:04:50,920
I mean, when I get the reports back, it's either there or it's not.

85
00:04:50,920 --> 00:04:51,920
It's very helpful.

86
00:04:51,920 --> 00:04:52,920
Exactly.

87
00:04:52,920 --> 00:04:53,920
Exactly.

88
00:04:53,920 --> 00:04:58,320
And the reason that's important is because if, let's say, there was one in the liver,

89
00:04:58,320 --> 00:05:01,960
if it's small, it doesn't really matter, but let's say there is one in the liver that's

90
00:05:01,960 --> 00:05:09,120
large, it could be pushing on the rest of the liver and impact its correct function.

91
00:05:09,120 --> 00:05:10,960
It could affect circulation.

92
00:05:10,960 --> 00:05:15,240
And there's even some, I believe, data about affecting thyroid.

93
00:05:15,240 --> 00:05:20,800
Yeah, it can definitely impact thyroid function, especially when you have diffuse hemangiomatosis

94
00:05:20,800 --> 00:05:21,800
on the liver.

95
00:05:21,800 --> 00:05:22,800
But...

96
00:05:22,800 --> 00:05:23,800
Again, this is all very rare stuff.

97
00:05:23,800 --> 00:05:27,960
Most of the time, even with multiple, there's nothing inside the body.

98
00:05:27,960 --> 00:05:28,960
Yeah.

99
00:05:28,960 --> 00:05:32,960
And most of the time, since you brought up the most usual presentation, most of the time

100
00:05:32,960 --> 00:05:34,500
these are isolated.

101
00:05:34,500 --> 00:05:40,400
I think one of the hardest parts for pediatricians and family medicine practitioners out there

102
00:05:40,400 --> 00:05:45,480
and parents is trying to figure out to differentiate between a flat hemangioma, what we might call

103
00:05:45,480 --> 00:05:49,680
like a superficial one, versus something like a port wine birthmark, which we're going to

104
00:05:49,680 --> 00:05:52,680
talk about in the second half of this show.

105
00:05:52,680 --> 00:05:56,760
But hemangiomas don't have to be flat when you first see them either.

106
00:05:56,760 --> 00:06:02,400
Want to talk a little bit about how they might show up from the way they involve the skin?

107
00:06:02,400 --> 00:06:04,920
So there's certainly ones that are flat.

108
00:06:04,920 --> 00:06:08,920
And there are some that are actually raised above the skin.

109
00:06:08,920 --> 00:06:11,760
And they can be quite significantly raised.

110
00:06:11,760 --> 00:06:15,440
And those will look very red.

111
00:06:15,440 --> 00:06:19,680
The reason why we call them "strawberry hemangiomas" is they often look like a strawberry.

112
00:06:19,680 --> 00:06:24,040
There are also ones that can present under the skin, which makes our job a little bit

113
00:06:24,040 --> 00:06:28,480
more challenging because when they're under the skin, they sometimes look blue.

114
00:06:28,480 --> 00:06:33,240
Just like when we look at our veins, our veins are full of red blood, but under the skin

115
00:06:33,240 --> 00:06:34,240
they look blue.

116
00:06:34,240 --> 00:06:39,160
So that can sometimes make the diagnosis a little bit more challenging because there

117
00:06:39,160 --> 00:06:44,880
are actually other things under the skin that can look blue that would be on the differential.

118
00:06:44,880 --> 00:06:47,560
And I've had some hemangiomas where there's no color at all.

119
00:06:47,560 --> 00:06:51,760
You have to get imaging and you find out, oh, it's a really deep hemangioma.

120
00:06:51,760 --> 00:06:55,240
You just can't see the surface of the thing to even know there's blood in there.

121
00:06:55,240 --> 00:06:57,720
So you can be fooled.

122
00:06:57,720 --> 00:07:05,400
Now you tell me how you approach your patients, but my sort of go-to spiel is, listen, just

123
00:07:05,400 --> 00:07:10,960
like you said, these things usually will follow a stereotypical course if we're lucky.

124
00:07:10,960 --> 00:07:12,880
They're going to maybe not be there at birth.

125
00:07:12,880 --> 00:07:14,320
They could be there at birth.

126
00:07:14,320 --> 00:07:19,560
That's one of the things that helps us differentiate between conditions like congenital hemangiomas,

127
00:07:19,560 --> 00:07:23,840
which are a little different than infantile hemangiomas, both in what they do, but also

128
00:07:23,840 --> 00:07:27,360
maybe how they even got there in the first place, which we can talk about if there's

129
00:07:27,360 --> 00:07:28,360
time.

130
00:07:28,360 --> 00:07:31,880
But most of the time there's really nothing there at birth.

131
00:07:31,880 --> 00:07:36,200
And then within, like I usually say, about a week or two, you'll see a cherry red spot

132
00:07:36,200 --> 00:07:38,320
that then grows pretty quickly.

133
00:07:38,320 --> 00:07:42,400
And I'll tell them to expect a lot of growth in the first three months, even up to like

134
00:07:42,400 --> 00:07:43,400
five months.

135
00:07:43,400 --> 00:07:45,280
I've seen some growth go.

136
00:07:45,280 --> 00:07:50,640
And then these infantile hemangiomas will sort of transition to what is called the plateau

137
00:07:50,640 --> 00:07:52,280
phase, where they're not doing anything.

138
00:07:52,280 --> 00:07:53,280
They're just hanging out.

139
00:07:53,280 --> 00:07:54,280
They're not getting bigger.

140
00:07:54,280 --> 00:07:55,880
They're not getting smaller.

141
00:07:55,880 --> 00:07:57,660
They're not causing any trouble.

142
00:07:57,660 --> 00:08:02,840
And then fingers crossed around, I don't know, I tell people usually around 10, 11, 12 months

143
00:08:02,840 --> 00:08:06,760
of age, fingers crossed, nature starts taking over.

144
00:08:06,760 --> 00:08:12,000
And without doing anything, most of these birthmarks, these infantile hemangiomas, start

145
00:08:12,000 --> 00:08:14,720
to want to go away on their own.

146
00:08:14,720 --> 00:08:19,640
And if you're lucky, I usually quote that about half of them are gone by the time you're

147
00:08:19,640 --> 00:08:20,760
five years of age.

148
00:08:20,760 --> 00:08:23,360
Is that about your spiel as well?

149
00:08:23,360 --> 00:08:24,360
Yeah.

150
00:08:24,360 --> 00:08:28,960
I say maybe 20% are gone at age two, 30% age three, et cetera.

151
00:08:28,960 --> 00:08:31,180
50% are gone at age five.

152
00:08:31,180 --> 00:08:35,600
Sometimes after that, if at age five it's still there, there is a chance it could always

153
00:08:35,600 --> 00:08:36,840
be there.

154
00:08:36,840 --> 00:08:41,300
Certainly involution can continue up to even seven, eight, nine years of age.

155
00:08:41,300 --> 00:08:43,560
But some of them actually don't resolve completely.

156
00:08:43,560 --> 00:08:46,960
But the vast majority will get flatter, lighter.

157
00:08:46,960 --> 00:08:50,380
Some completely disappear where you see literally no trace.

158
00:08:50,380 --> 00:08:54,520
But the other thing that can sometimes happen is when they go through their growth phase,

159
00:08:54,520 --> 00:08:57,200
they stretch out the tissue a little bit.

160
00:08:57,200 --> 00:09:02,120
So even though they do get lighter and smaller over time, sometimes the hemangioma may be

161
00:09:02,120 --> 00:09:03,120
gone.

162
00:09:03,120 --> 00:09:06,120
But later in life, you see almost like a little pooch of the skin.

163
00:09:06,120 --> 00:09:07,120
Yeah.

164
00:09:07,120 --> 00:09:12,880
I caution my patients with hemangiomas that there's going to be, think of it like a "scaffolding,"

165
00:09:12,880 --> 00:09:16,000
what someone's doing, putting a new roof on your home.

166
00:09:16,000 --> 00:09:20,440
And to get that roof there in the first place, you need to build the scaffolding on the side

167
00:09:20,440 --> 00:09:25,040
of the house that allows those roofers to get up top there and build their roof.

168
00:09:25,040 --> 00:09:29,160
In this case, the roof are the blood vessels of the hemangioma.

169
00:09:29,160 --> 00:09:34,200
And that scaffolding is that connective tissue that then hangs around and leaves, if everything

170
00:09:34,200 --> 00:09:39,680
else goes away, it could leave behind this sort of residual, I think, or fibro fatty residual,

171
00:09:39,680 --> 00:09:40,680
I've heard it called.

172
00:09:40,680 --> 00:09:42,800
And that's a little harder to treat.

173
00:09:42,800 --> 00:09:44,040
But it still can be treated.

174
00:09:44,040 --> 00:09:48,960
And that's where the decision comes as to whether or not you want to treat based on

175
00:09:48,960 --> 00:09:52,160
the location of the lesion, et cetera.

176
00:09:52,160 --> 00:09:53,640
Because we do have treatment, of course.

177
00:09:53,640 --> 00:09:59,560
And that's where I kind of begin to speak with the parents on, do we want to treat or

178
00:09:59,560 --> 00:10:00,560
not?

179
00:10:00,560 --> 00:10:01,560
Yeah.

180
00:10:01,560 --> 00:10:06,480
So before we get into how we would actively manage these things, optimistically, what

181
00:10:06,480 --> 00:10:10,640
do you tell patients and their families to look out for signs that these things might

182
00:10:10,640 --> 00:10:11,640
be going away?

183
00:10:11,640 --> 00:10:13,560
That they might be getting ready to get ready?

184
00:10:13,560 --> 00:10:16,160
It's almost like a grape turning into a raisin.

185
00:10:16,160 --> 00:10:21,440
Sometimes they start to sort of dry up, shrivel up, get a little flatter, lighter.

186
00:10:21,440 --> 00:10:24,760
You see almost like a whitish discoloration.

187
00:10:24,760 --> 00:10:30,680
And so that's, especially in involution phase, that's when I tell parents to watch out for

188
00:10:30,680 --> 00:10:36,160
something called "ulceration," which is sometimes they dry up, shrink down so much that they

189
00:10:36,160 --> 00:10:37,800
can even open up.

190
00:10:37,800 --> 00:10:42,480
Yeah, and also in the rapidly growth phase, if you've got one that's really growing quickly,

191
00:10:42,480 --> 00:10:47,120
you might see, classically they say there's like a white streak that you might see as

192
00:10:47,120 --> 00:10:49,400
an impending sign of doom.

193
00:10:49,400 --> 00:10:55,280
But yeah, I'll look for mottling where the color, that red color, a violaceous color

194
00:10:55,280 --> 00:10:59,320
will turn, darker purple and start to break up a little bit.

195
00:10:59,320 --> 00:11:01,000
And it gets softer too.

196
00:11:01,000 --> 00:11:05,920
You can palpably feel it changing under your fingers, usually, that it's getting softer.

197
00:11:05,920 --> 00:11:10,160
And man, even within a couple of days, sometimes you'll see a difference in terms of what this

198
00:11:10,160 --> 00:11:11,160
thing looks like.

199
00:11:11,160 --> 00:11:12,160
It's pretty magical.

200
00:11:12,160 --> 00:11:15,260
Who's at risk for getting infantile hemangiomas?

201
00:11:15,260 --> 00:11:19,480
So any baby could have them, but there is some data in the literature that shows that

202
00:11:19,480 --> 00:11:23,240
it's a little bit more likely in a female baby.

203
00:11:23,240 --> 00:11:26,760
Babies born prematurely.

204
00:11:26,760 --> 00:11:33,480
And the reason for that, we don't completely understand, but there's some, there's a hypothesis

205
00:11:33,480 --> 00:11:40,520
that might have something to do with a lack of oxygen compared to full term babies, but

206
00:11:40,520 --> 00:11:44,640
I would say female and premature babies most common.

207
00:11:44,640 --> 00:11:46,640
Do they still say twins are more at risk?

208
00:11:46,640 --> 00:11:47,640
I think so, right?

209
00:11:47,640 --> 00:11:49,240
Maybe, yeah, multiple gestation.

210
00:11:49,240 --> 00:11:52,880
And then the question is also, could that be due to prematurity too?

211
00:11:52,880 --> 00:11:54,400
Right, right, of course.

212
00:11:54,400 --> 00:11:59,280
Low birth weight, I think is, that's probably one of the bigger things that I think of.

213
00:11:59,280 --> 00:12:01,280
But we saw tons of them.

214
00:12:01,280 --> 00:12:02,280
I mean, that's for sure.

215
00:12:02,280 --> 00:12:09,640
We - you and I - trained and practiced in a time where the only treatments really were giving

216
00:12:09,640 --> 00:12:16,360
it time and letting nature do its thing or putting kids on systemic steroids or even

217
00:12:16,360 --> 00:12:21,640
worse, something like an anti-cancer medicine in the real bad cases.

218
00:12:21,640 --> 00:12:26,440
And that's, we were, I think, I don't use the word lightly, but we were sort of blessed

219
00:12:26,440 --> 00:12:30,240
to witness what, at least I tell people was the first miracle I've ever seen in medicine,

220
00:12:30,240 --> 00:12:33,880
you know, the birth of oral propranolol.

221
00:12:33,880 --> 00:12:38,240
Oh, yes, that was right when we were in residency that they discovered it.

222
00:12:38,240 --> 00:12:43,480
And I remember before then we'd have babies on prednisone for months, which we know is,

223
00:12:43,480 --> 00:12:45,280
you know, not an ideal situation.

224
00:12:45,280 --> 00:12:48,720
I remember even ones where they were close to the eye, they used to have to inject steroids

225
00:12:48,720 --> 00:12:49,720
into them.

226
00:12:49,720 --> 00:12:51,720
So it was such a miracle.

227
00:12:51,720 --> 00:12:57,520
Putting a needle into a kid's eye and hoping that the medicine you're injecting

228
00:12:57,520 --> 00:13:02,440
is going to save their vision was a different experience.

229
00:13:02,440 --> 00:13:04,520
And we were pretty fortunate.

230
00:13:04,520 --> 00:13:08,360
We trained at a place where, you know, one of your colleagues there at Scripps, Sheila

231
00:13:08,360 --> 00:13:15,640
Friedlander, MD - when she worked there - she was absolutely on the cutting edge of what was

232
00:13:15,640 --> 00:13:18,000
going on in hemangiomas in general.

233
00:13:18,000 --> 00:13:23,600
And then I think literally you and I were there when we were doing some of the biggest

234
00:13:23,600 --> 00:13:29,920
research and clinical trials around the medicine that eventually came out to be the "gold standard"

235
00:13:29,920 --> 00:13:32,320
for treatment, the stuff, oral propranolol.

236
00:13:32,320 --> 00:13:35,360
And I think it's so amazing how they figured it out initially, too.

237
00:13:35,360 --> 00:13:39,000
They were treating babies in a hospital.

238
00:13:39,000 --> 00:13:40,640
Was it in Spain or something?

239
00:13:40,640 --> 00:13:42,640
France, Bordeaux, France.

240
00:13:42,640 --> 00:13:46,160
Who needed propranolol for, I think, cardiac indications.

241
00:13:46,160 --> 00:13:49,800
And some of them happened to have hemangiomas and they started to notice that they were

242
00:13:49,800 --> 00:13:50,800
getting better.

243
00:13:50,800 --> 00:13:52,080
And that's how it all started.

244
00:13:52,080 --> 00:14:01,520
To me, that lady who, I mean, granted, she got her respectful dues by getting a publication

245
00:14:01,520 --> 00:14:03,000
out of New England Journal of Medicine.

246
00:14:03,000 --> 00:14:06,600
And anybody who knows the story, you know, thinks she walks on water.

247
00:14:06,600 --> 00:14:14,680
But just if you pull up at 50,000 feet and just understand what it took

248
00:14:14,680 --> 00:14:16,200
for her to figure this out.

249
00:14:16,200 --> 00:14:23,320
I mean, like you said, she had a kid on, from what I understand the story to be, was she

250
00:14:23,320 --> 00:14:29,360
got called for a consult in the neonatal intensive care unit at the hospital that she was at

251
00:14:29,360 --> 00:14:31,640
for a couple of kids with hemangiomas.

252
00:14:31,640 --> 00:14:36,120
And just in parallel, they had been started on an oral beta-blocker, or probably actually

253
00:14:36,120 --> 00:14:39,240
was probably systemic, I would think, because it was the NICU.

254
00:14:39,240 --> 00:14:44,720
And she was able to then do two things, which I give her way more credit than what I would

255
00:14:44,720 --> 00:14:45,720
have been able to do.

256
00:14:45,720 --> 00:14:48,280
A, she pieced this all together.

257
00:14:48,280 --> 00:14:53,720
And B, she did it because she actually went back very quickly to check on how these kids

258
00:14:53,720 --> 00:14:59,960
were doing after she started them on oral steroids, and realized that,

259
00:14:59,960 --> 00:15:02,840
geez, I think this is too soon.

260
00:15:02,840 --> 00:15:07,680
The effect that we're seeing is too soon to have been the consequence of these steroids,

261
00:15:07,680 --> 00:15:10,800
which we know took months and months and months to work.

262
00:15:10,800 --> 00:15:13,280
And somehow she was able to put that together in her brain.

263
00:15:13,280 --> 00:15:17,000
And to me, that is like, I don't know, at least within the world of dermatology, that's

264
00:15:17,000 --> 00:15:21,880
Nobel Prize worthy, because she made that connection and then had the guts to look at

265
00:15:21,880 --> 00:15:26,040
it more formally, write it up, submit it to the New England Journal of Medicine as a brief

266
00:15:26,040 --> 00:15:27,040
report.

267
00:15:27,040 --> 00:15:29,400
And now it's the gold standard.

268
00:15:29,400 --> 00:15:33,760
And it's totally changed the way we do things, thankfully.

269
00:15:33,760 --> 00:15:41,040
And so before we dive into management, because that's obviously one of the positive sides

270
00:15:41,040 --> 00:15:48,960
of this discussion, you mentioned a little bit about how hypoxia may play a role.

271
00:15:48,960 --> 00:15:53,920
Do you remember when you were training what the old thoughts were that this was caused

272
00:15:53,920 --> 00:15:54,920
by?

273
00:15:54,920 --> 00:15:59,520
I don't want to plant that in your head, but I kind of have a weird story in my mind of

274
00:15:59,520 --> 00:16:04,880
being told what this was and going, oh, that's interesting, and then just buying it as totally

275
00:16:04,880 --> 00:16:08,600
ex-cathedra, but then figuring out that down the line that that didn't make any sense.

276
00:16:08,600 --> 00:16:09,600
Does that trigger anything?

277
00:16:09,600 --> 00:16:11,880
No, no.

278
00:16:11,880 --> 00:16:21,680
So I remember being told that this was probably a chunk of mom's placenta that got broken

279
00:16:21,680 --> 00:16:26,120
off and was now being passed through the kid and was quote-unquote "growing."

280
00:16:26,120 --> 00:16:27,600
Oh, and that's what the hemangioma is?

281
00:16:27,600 --> 00:16:28,600
Oh, yeah.

282
00:16:28,600 --> 00:16:29,600
I know.

283
00:16:29,600 --> 00:16:30,600
I never heard that.

284
00:16:30,600 --> 00:16:32,680
And I was, wow, my goodness, that sounds horrifying.

285
00:16:32,680 --> 00:16:35,240
And then you're like, yeah, that's probably not really it.

286
00:16:35,240 --> 00:16:41,800
But to your point, a lot of research has been done and this concept that hypoxia, that's

287
00:16:41,800 --> 00:16:46,520
the technical term for it, but just lower oxygen levels in the tissue.

288
00:16:46,520 --> 00:16:52,280
Not that the baby is suffering from any sort of low oxygen state, but the idea that the

289
00:16:52,280 --> 00:16:58,040
skin itself took a little miniature "hit" in terms of how much oxygen was going through

290
00:16:58,040 --> 00:16:59,040
it.

291
00:16:59,040 --> 00:17:02,920
And then could it be compensating by then sort of bursting out with blood vessels that

292
00:17:02,920 --> 00:17:09,600
try to get more blood to that area because that area particularly was lower in oxygen.

293
00:17:09,600 --> 00:17:13,480
That to me not only makes sense, but it's backed up by a little bit of the science.

294
00:17:13,480 --> 00:17:18,920
So we know these infantile hemangiomas, they're Glut-1 positive.

295
00:17:18,920 --> 00:17:24,320
Can you speak at all about how you use Glut-1 as a marker for these things?

296
00:17:24,320 --> 00:17:25,320
Yeah.

297
00:17:25,320 --> 00:17:28,240
Glut-1 is "glucose transporter 1."

298
00:17:28,240 --> 00:17:34,640
And one of the things we actually do in the clinic, for example, let's say we don't know

299
00:17:34,640 --> 00:17:39,080
if it really is a hemangioma or it's like one of those subcutaneous ones and we're not

300
00:17:39,080 --> 00:17:42,960
sure if it is one and that determines how we treat it.

301
00:17:42,960 --> 00:17:49,480
If you actually take a biopsy of a hemangioma, you can actually stain it for that and that

302
00:17:49,480 --> 00:17:54,440
can help you determine if it's a hemangioma versus some other sort of venous malformation

303
00:17:54,440 --> 00:17:55,480
or whatever.

304
00:17:55,480 --> 00:18:00,040
And if the biopsy is Glut-1 positive, you then know it is a hemangioma.

305
00:18:00,040 --> 00:18:03,200
It's super specific to these particular things, right?

306
00:18:03,200 --> 00:18:07,520
And it can be helpful too because there's some rare variants of hemangioma, not really

307
00:18:07,520 --> 00:18:10,680
a variant but an alternative type of vascular lesion.

308
00:18:10,680 --> 00:18:15,880
There's one called a congenital-type hemangioma and there's actually two different ones,

309
00:18:15,880 --> 00:18:21,960
a non-involuting congenital hemangioma and a rapidly involuting congenital hemangioma that

310
00:18:21,960 --> 00:18:27,480
look very similar but have different courses and one of the things we do to differentiate

311
00:18:27,480 --> 00:18:32,640
a hemangioma of infancy from them is actually do the staining on a biopsy.

312
00:18:32,640 --> 00:18:37,920
And, God forbid, there are a couple scarier "blue things" that can start to grow in kids

313
00:18:37,920 --> 00:18:42,040
that we know about, tufted angiomas and let's see if I can say this one correctly.

314
00:18:42,040 --> 00:18:43,040
The Kaposiform hemangioendothelioma.

315
00:18:43,040 --> 00:18:44,040
Hachoo!

316
00:18:44,040 --> 00:18:46,040
It's a mouthful.

317
00:18:46,040 --> 00:18:52,800
But those two are famous because they can cause a devastating problem called Kasabach-

318
00:18:52,800 --> 00:18:58,720
Merritt Syndrome where platelets get kind of stuck inside the lesion.

319
00:18:58,720 --> 00:19:03,760
Totally something that we don't see in infantile hemangiomas but sometimes you don't know

320
00:19:03,760 --> 00:19:07,280
and biopsying can make the difference for you.

321
00:19:07,280 --> 00:19:12,440
But that said, when's the last time you biopsied a hemangioma?

322
00:19:12,440 --> 00:19:17,960
Not often because hemangiomas are made of blood vessels and when you're in your outpatient

323
00:19:17,960 --> 00:19:23,640
clinic without an OR you have the risk of bleeding.

324
00:19:23,640 --> 00:19:27,120
So not my favorite thing to do.

325
00:19:27,120 --> 00:19:32,480
Yeah I think we did it a couple times maybe during training but at least in the last five

326
00:19:32,480 --> 00:19:37,000
years I have not stuck anything into a hemangioma.

327
00:19:37,000 --> 00:19:43,300
Rather than I guess stuck on might be a way to phrase it, I think we're in a time now

328
00:19:43,300 --> 00:19:50,920
where some of the management options that we have do afford us a week, a two weeks period

329
00:19:50,920 --> 00:19:56,520
where we can actually say hey let's try these medicines that really should only work on

330
00:19:56,520 --> 00:19:58,360
infantile hemangiomas.

331
00:19:58,360 --> 00:20:04,800
It would be very helpful I think to have almost automatically when you're asking that ultrasound

332
00:20:04,800 --> 00:20:09,480
a hemangioma would be great if the radiologist automatically did the flow.

333
00:20:09,480 --> 00:20:11,680
Sometimes you have to go back and ask for that to be done.

334
00:20:11,680 --> 00:20:14,000
I don't know about your institution but.

335
00:20:14,000 --> 00:20:15,000
We do have to ask.

336
00:20:15,000 --> 00:20:18,080
One of the things I wish we had been trained to do it ourselves even.

337
00:20:18,080 --> 00:20:19,680
Oh that would be great right?

338
00:20:19,680 --> 00:20:23,600
Right at the bedside would save a lot of people a lot of worries but ultimately we get the

339
00:20:23,600 --> 00:20:29,320
answer and it is very reassuring when you see that it's a "fast flow" lesion

340
00:20:29,320 --> 00:20:35,160
not "pulsatile" like you said in arteriovenous malformation in AVM.  Not a slow flow lesion

341
00:20:35,160 --> 00:20:39,320
like a venous malformation but the blood going through these tiny little capillaries that

342
00:20:39,320 --> 00:20:42,720
make up this what really is a tumor of blood vessels, right?

343
00:20:42,720 --> 00:20:47,520
That's a big thing that and a scary thing to hear for parents but when you're kind of

344
00:20:47,520 --> 00:20:54,940
looking at red birthmarks on a kid the way at least I kind of characterize them and make

345
00:20:54,940 --> 00:21:02,280
the first split...is this a tumor of blood vessels or is this a malformation of some vasculature

346
00:21:02,280 --> 00:21:08,880
and hemangiomas fall into what is technically a bucket of tumors in the sense that it's

347
00:21:08,880 --> 00:21:12,880
not a cancer it's not going to spread and take over the person's body but it's a tumor

348
00:21:12,880 --> 00:21:17,960
it's not supposed to be there and it's living growing tissue that has sort of connected

349
00:21:17,960 --> 00:21:21,440
itself in a place that's not supposed to be.

350
00:21:21,440 --> 00:21:28,040
Speaking of places where it's not supposed to be what anatomic locations get you nervous?

351
00:21:28,040 --> 00:21:36,600
Well the two main ones would be face with that having both medical and cosmetic implications

352
00:21:36,600 --> 00:21:41,680
and then the second one would be the genital area and there's a couple of reasons let's

353
00:21:41,680 --> 00:21:46,840
start with the face so I always tell my patients there's two issues medical and cosmetic so

354
00:21:46,840 --> 00:21:53,080
medically on the face especially in places for example can you imagine on the eyelid

355
00:21:53,080 --> 00:21:59,120
where a hemangioma might grow and push on the eye or impede the baby's ability to open

356
00:21:59,120 --> 00:22:02,960
their eye that can affect vision.

357
00:22:02,960 --> 00:22:08,600
On the nose...imagine, you know, it being near the airway.  It can affect a baby's ability

358
00:22:08,600 --> 00:22:13,400
to breathe.  And then certainly on the mouth...the baby's ability to feed and

359
00:22:13,400 --> 00:22:18,640
then another consideration would be the size of the hemangioma because there's this rare

360
00:22:18,640 --> 00:22:24,120
condition we call it PHACE syndrome where you have a large hemangioma commonly kind

361
00:22:24,120 --> 00:22:30,640
of in this distribution of the "beard" area there's a condition called PHACES syndrome.

362
00:22:30,640 --> 00:22:40,440
P-H-A-C-E stands for the P is for posterior fossa malformations

363
00:22:40,440 --> 00:22:48,000
The H is for hemangioma. The A is for arterial anomalies.  The C is for cardiac defects or

364
00:22:48,000 --> 00:22:56,000
also actually aortic coarctation, and the E is for eye anomalies and the most common location

365
00:22:56,000 --> 00:23:01,560
for this syndrome is to have a hemangioma on the face so I don't know what your experience

366
00:23:01,560 --> 00:23:02,880
with those has been.

367
00:23:02,880 --> 00:23:07,180
We've had a couple over the last five years that we've had St. Luke's Dermatology up

368
00:23:07,180 --> 00:23:15,320
and running, and they they've ranged from being caught early on and being effectively

369
00:23:15,320 --> 00:23:22,160
managed now with the oral propranol that we have to having some kids that have had consequences

370
00:23:22,160 --> 00:23:27,720
where you know it would have been impossible to prevent but that they've had some of those

371
00:23:27,720 --> 00:23:32,600
other findings that you mentioned.  More specifically, the the heart stuff is seemingly

372
00:23:32,600 --> 00:23:38,080
what we tend to find, not - thank God! - not a lot of brain issues or but the but they'll

373
00:23:38,080 --> 00:23:44,400
have some heart associated defect and you kind of just lump that in together and say

374
00:23:44,400 --> 00:23:48,360
this would be consistent with PHACE syndrome even if it's totally unrelated

375
00:23:48,360 --> 00:23:52,700
because we don't have a way to test both directly and say oh yeah this is the this is because

376
00:23:52,700 --> 00:23:54,640
of the same thing.

377
00:23:54,640 --> 00:23:58,560
And not only for the facial hemangioma is the medical side, which is clearly the most

378
00:23:58,560 --> 00:24:03,120
important there's the cosmetic side too. I mean you have this large tumor growing on

379
00:24:03,120 --> 00:24:04,960
your beautiful child's face.

380
00:24:04,960 --> 00:24:11,080
It can distort the tissue we know that they involute in the future but you might be you

381
00:24:11,080 --> 00:24:17,000
know left with stretched out tissue right in the middle of your face so and which is

382
00:24:17,000 --> 00:24:18,000
very concerning.

383
00:24:18,000 --> 00:24:24,640
Yeah so I kind of approach it just exactly like you have...is this hemangioma

384
00:24:24,640 --> 00:24:31,960
going to pose a functional risk and will it pose a long term cosmetic risk.  And I think

385
00:24:31,960 --> 00:24:38,040
you hit it on the head... Eyes.  So we have a wonderful pediatric ophthalmologist that we work with

386
00:24:38,040 --> 00:24:45,720
that gets these kids in very quickly, makes sure that the optic nerve is intact that there's

387
00:24:45,720 --> 00:24:51,960
no findings of PHACE.  If there is one that's growing close to the eyelid margin you could

388
00:24:51,960 --> 00:24:56,720
imagine if you're catching that early enough that you're going to maybe see some rapid

389
00:24:56,720 --> 00:25:01,640
growth over the next few weeks.  This thing could grow literally up and into the field

390
00:25:01,640 --> 00:25:07,960
of vision so - it's really interesting! - the ophthalmologist will have - and I only learned this by training

391
00:25:07,960 --> 00:25:11,280
in pediatric dermatology but for the people out there who never would have thought this

392
00:25:11,280 --> 00:25:19,360
through you actually in those cases - you will purposefully have the child block the unaffected

393
00:25:19,360 --> 00:25:25,960
eye, the eye where the hemangioma is NOT.  And that forces the kid to use the vision of the

394
00:25:25,960 --> 00:25:31,040
eye that is being somewhat interrupted by the hemangioma and that keeps those optic

395
00:25:31,040 --> 00:25:37,240
nerve pathways intact and alive, because in pediatrics there is this true phenomenon of

396
00:25:37,240 --> 00:25:41,480
"Use it or lose it!" Right?  So you want to keep both of those eyes working

397
00:25:41,480 --> 00:25:46,600
equally and it's kind of cool when you get those kids in and you can make a

398
00:25:46,600 --> 00:25:51,800
real difference for them long term.  Nose, for sure. we've involved pediatric Ears, Nose and

399
00:25:51,800 --> 00:25:58,160
Throat (ENT) in a bunch of cases and probably even more so for the "beard" area. Yeah, how about

400
00:25:58,160 --> 00:26:02,040
the "beard" area?  You want to chat a little bit about that?  It can actually push on your airway

401
00:26:02,040 --> 00:26:08,400
or esophagus so and there's some cases where the hemangioma itself might clinically appear

402
00:26:08,400 --> 00:26:13,440
from the outside is completely flat but actually has a deeper component. I remember a case that

403
00:26:13,440 --> 00:26:19,680
in residency where a what we thought was previously just a flat hemangioma the child

404
00:26:19,680 --> 00:26:26,160
presented to the ER with stridor and after imaging and scoping by ENT it turns out it actually

405
00:26:26,160 --> 00:26:31,240
was pushing much below and of course we could fix that with propranolol but it was

406
00:26:31,240 --> 00:26:38,120
quite scary.  Yes, what's stridor for the audience?  It's a funny sound that babies will

407
00:26:38,120 --> 00:26:46,840
will make almost like a...Can you replicate it?  Yeah, yeah almost like...GASP. Maybe, is that

408
00:26:46,840 --> 00:26:52,080
pretty good stridor?  Yeah I don't know. Yeah it's just almost like gasping and and it's

409
00:26:52,080 --> 00:26:58,560
frightening because the the hemangioma can grow really quickly and actually require the

410
00:26:58,560 --> 00:27:04,080
baby to be intubated if not treated quickly. Yeah so for anyone listening out there

411
00:27:04,080 --> 00:27:08,480
if you happen to have an infantile hemangioma on your child in the sort of the

412
00:27:08,480 --> 00:27:13,520
"beard" area where you might be able to grow a beard that's a clue for

413
00:27:13,520 --> 00:27:20,640
a kid - a baby.  You can't put them on a treadmill and do a "stress test" so for the

414
00:27:20,640 --> 00:27:25,840
kid that stress test is usually eating.  They're chugging away on the bottle or the breast

415
00:27:25,840 --> 00:27:30,600
and they're really using all of their energy and so if you've got one

416
00:27:30,600 --> 00:27:36,200
of those birthmarks in that area and you're hearing your child make a sound that suggests

417
00:27:36,200 --> 00:27:40,600
he or she's having trouble breathing that can be a real big sign that you need

418
00:27:40,600 --> 00:27:44,300
to get in there and see somebody and not be told that you'll get into the dermatologist

419
00:27:44,300 --> 00:27:48,400
nine months from now.  You got to just show up at the door and make sure someone sees

420
00:27:48,400 --> 00:27:54,380
you pretty quickly.  One other area that I forgot to mention, too, is the ear.  What could seem

421
00:27:54,380 --> 00:27:58,540
like a superficial hemangioma can actually have a deeper component and affect the development

422
00:27:58,540 --> 00:28:04,240
of your ear or hearing of your child.  So cosmetically I've actually had two patients now where if

423
00:28:04,240 --> 00:28:09,240
the top of the ear for lack of a better anatomical description is involved that the

424
00:28:09,240 --> 00:28:14,560
ear itself sometimes there'll be a segmental hemangioma that's part of that ear but

425
00:28:14,560 --> 00:28:20,560
then also kind of spills onto the scalp and in those particular cases it really did deform

426
00:28:20,560 --> 00:28:26,320
the top of the ear.  In one child that sort of ulcerated and left the child with almost

427
00:28:26,320 --> 00:28:32,720
like a bite out of the top of her ear, and the other child was left with sort of a bent

428
00:28:32,720 --> 00:28:38,720
ear lobe as a result of that so that's a really important both functional and cosmetic area

429
00:28:38,720 --> 00:28:44,040
for sure.  How about in the diaper area?  Where do you get into trouble with hemangiomas?  So

430
00:28:44,040 --> 00:28:50,520
same issue medical first most important depending on how big it is or where it's located it

431
00:28:50,520 --> 00:28:58,840
can affect a baby's ability to urinate or stool. I've had a baby where

432
00:28:58,840 --> 00:29:03,040
it completely impacted the perianal area and we had to do propranolol so the baby could

433
00:29:03,040 --> 00:29:08,720
even have a bowel movement.  You know it was blocking their ability to

434
00:29:08,720 --> 00:29:16,320
poop.  Yes okay yes and there's also a rare condition especially with a very large hemangioma

435
00:29:16,320 --> 00:29:22,000
we call it a segmental hemangioma.  There's sort of the the opposite of PHACE syndrome

436
00:29:22,000 --> 00:29:30,520
in the area we call it LUMBAR syndrome:  L U M B A R.  Basically it's a lower body hemangioma

437
00:29:30,520 --> 00:29:40,000
is the L.  The U stands for urogenital anomalies and ulceration.  The M stands for myelopathy.

438
00:29:40,000 --> 00:29:48,240
The B stands for bony deformity excuse me.  The A stands for anorectal malformations

439
00:29:48,240 --> 00:29:55,120
of which there can be multiple and also arterial anomalies, and then the R stands for renal

440
00:29:55,120 --> 00:30:01,640
anomalies..  And so I actually had one in clinic in the last year who presented with a large hemangioma

441
00:30:01,640 --> 00:30:08,160
basically from the top of the labia all the way to the buttocks on both sides had to be

442
00:30:08,160 --> 00:30:16,600
worked up for this.  And what we do is some MRI imaging to check not only the urogenital

443
00:30:16,600 --> 00:30:22,760
area also the lower spine and fortunately this baby turned out to be totally fine.  It

444
00:30:22,760 --> 00:30:27,840
was an isolated hemangioma but you have to look for these other anomalies.  Yeah that

445
00:30:27,840 --> 00:30:34,360
must have been horrifying.  Thankfully that's pretty rare correct?  And and so

446
00:30:34,360 --> 00:30:38,800
once you rule that out the main issue in that area is then because you know you can imagine

447
00:30:38,800 --> 00:30:44,880
having a large growth in your diaper what's the main issue that happens?  You have you know

448
00:30:44,880 --> 00:30:50,120
stool, urine in the diaper and you can get actually erosions, ulcerations which present

449
00:30:50,120 --> 00:30:55,480
not only in a very painful way but also at a high risk for infection and bleeding. My

450
00:30:55,480 --> 00:31:01,040
spiel for that is, you know, if you think about it urine's got ammonia in it and all the digestive

451
00:31:01,040 --> 00:31:08,360
enzymes that start from your mouth all the way down to your anus winds up getting dumped

452
00:31:08,360 --> 00:31:13,840
into the diaper. These diapers are right up against the skin.  Even without a hemangioma

453
00:31:13,840 --> 00:31:19,880
you can get "diaper dermatitis" a diaper rash where the real underlying cause is simply

454
00:31:19,880 --> 00:31:25,480
just an irritation from those materials up against the skin.  Now you're putting those

455
00:31:25,480 --> 00:31:32,840
same caustic chemicals onto not normal skin but this infantile hemangioma skin - segmental

456
00:31:32,840 --> 00:31:38,120
or otherwise.  It can just be a normal little hemangioma and, man, I find that that

457
00:31:38,120 --> 00:31:43,760
skin is particularly friable and will ulcerate a little bit more easily. So what happened

458
00:31:43,760 --> 00:31:46,880
when we're talking about ulcerating...You want to explain what sort of that phenomenon is?

459
00:31:46,880 --> 00:31:52,360
What do we mean when we say a hemangioma ulcerates?  So for example in the growth phase as they

460
00:31:52,360 --> 00:31:58,280
get larger sometimes the superficial portion of the lesion actually almost looks

461
00:31:58,280 --> 00:32:03,200
like a small tear of the skin as it stretches out

462
00:32:03,200 --> 00:32:07,080
and then it'll gradually open up and make a sore that can actually get wider and deeper

463
00:32:07,080 --> 00:32:12,200
over time as the hemangioma grows and you can imagine having a sore rubbing against

464
00:32:12,200 --> 00:32:19,000
the diaper.  It's very painful one of the things I think parents should hear is that yes this

465
00:32:19,000 --> 00:32:24,360
is for lack of a better description a big tumor full of blood but when when we get an

466
00:32:24,360 --> 00:32:31,080
ulceration when the skin breaks down it's not going to show up as a bursting water balloon

467
00:32:31,080 --> 00:32:35,300
of blood.  That's what all the parents think is going to happen.  Yeah sometimes they miss

468
00:32:35,300 --> 00:32:40,760
it.  They miss the fact that the skin that's overlying these things is getting eroded and

469
00:32:40,760 --> 00:32:46,980
chewed up and is basically like you skin your leg. You can look for a surface change

470
00:32:46,980 --> 00:32:53,160
that's really what we're talking about and, man, it hurts when you have 

471
00:32:53,160 --> 00:32:58,180
any break in your skin.  A paper cut even feels not great to an adult.  Imagine what this would

472
00:32:58,180 --> 00:33:03,400
feel like in your diaper area for a little baby.  On top of that like you said any of those

473
00:33:03,400 --> 00:33:07,760
microbes especially in the diaper area from the poop are getting now into the skin when

474
00:33:07,760 --> 00:33:12,160
it normally shouldn't.  Anything can get in there and cause an infection which then can

475
00:33:12,160 --> 00:33:18,280
really exacerbate all those problems so we we take it very very seriously and act very

476
00:33:18,280 --> 00:33:24,500
aggressively when an ulcerated hemangioma presents.  What's your sort of... what do you do

477
00:33:24,500 --> 00:33:29,960
extra in terms of management for those kinds of things?  You mean apart from using things

478
00:33:29,960 --> 00:33:34,440
like propranol?  Yeah yeah.  Well, what else would you do for those?  So I tell the

479
00:33:34,440 --> 00:33:40,760
parents how important it is to keep the area well hydrated.  We have various different brands

480
00:33:40,760 --> 00:33:46,040
of petrolatum-based products that you can use in the area so I I counsel with every

481
00:33:46,040 --> 00:33:51,400
diaper change you may want to put a layer on top as well as a barrier cream something

482
00:33:51,400 --> 00:33:56,480
for example with zinc oxide to protect the hemangioma from rubbing against the diaper.

483
00:33:56,480 --> 00:34:03,720
That's great.  We've even had to prescribe topical lidocaine at times, and

484
00:34:03,720 --> 00:34:08,120
we use metronidazole a lot for when it's in the diaper area just to try to control some

485
00:34:08,120 --> 00:34:13,560
of the poop associated bacteria.  I don't know if that's something you guys do but same thing.

486
00:34:13,560 --> 00:34:18,880
But since we've been beaten around the bush here now what  would your "go to" be

487
00:34:18,880 --> 00:34:25,000
to treat any hemangioma where it's functionally at risk for causing problems or cosmetically

488
00:34:25,000 --> 00:34:30,680
at risk for causing problems? What's your sort of management approach?  So what I

489
00:34:30,680 --> 00:34:35,700
do is I introduce the family to the concept of there being both an oral and a topical

490
00:34:35,700 --> 00:34:42,840
beta-blocker available.  The oral - the most common one we use is propranolol - and the topical being

491
00:34:42,840 --> 00:34:50,880
timolol and what I present it as is an opportunity to shrink the hemangioma down in size and

492
00:34:50,880 --> 00:34:58,200
it also improves the color but also helps lower the risk of development of these ulcerations

493
00:34:58,200 --> 00:35:03,280
But the most important thing I talk about with families is that before starting anything

494
00:35:03,280 --> 00:35:08,040
like this the decision has to be made as to whether you want to do the oral versus the

495
00:35:08,040 --> 00:35:13,480
topical based on the risk and with those risks being the most important ones being the risk

496
00:35:13,480 --> 00:35:19,560
of lowering your baby's blood pressure pulse and blood sugar and you and 

497
00:35:19,560 --> 00:35:23,640
the problem with that is these are babies and not adults an adult's blood pressure is

498
00:35:23,640 --> 00:35:30,760
you know 120 over 80 a baby's blood pressure might be 80 over 50 at baseline and the problem

499
00:35:30,760 --> 00:35:35,240
with lowering a blood pressure is then you don't get enough blood profusion to vital

500
00:35:35,240 --> 00:35:40,960
organs like your brain so you have to be very careful with these medications.  We don't just

501
00:35:40,960 --> 00:35:47,040
give them to every baby.  There there especially in smaller ones there is opportunity to start

502
00:35:47,040 --> 00:35:51,840
with for example a topical version of this which is the timolol which has a lower risk

503
00:35:51,840 --> 00:35:57,880
of those side effects although not zero and to a couple more side effects that are very

504
00:35:57,880 --> 00:36:06,360
rare if a baby has asthma you could increase the baby's risk of wheezing if the baby.  So

505
00:36:06,360 --> 00:36:11,720
there's this rare thing we call night terrors that you can get with beta-blockers which

506
00:36:11,720 --> 00:36:17,600
is basically in a nutshell the baby wakes up from sleep screams shouts falls back asleep

507
00:36:17,600 --> 00:36:22,440
right away, which is very hard to differentiate from normal baby behavior at that age anyway.

508
00:36:22,440 --> 00:36:25,720
But I always tell parents if it seems like it's happening more often it could be the

509
00:36:25,720 --> 00:36:31,560
medicine and then I've also had a couple rare GI side effects there are reports of

510
00:36:31,560 --> 00:36:35,760
constipation but I've also had actually some have the opposite effect.  I don't know what

511
00:36:35,760 --> 00:36:41,240
your experience is absolutely and and so reflux as well the baby's like spinning up a little

512
00:36:41,240 --> 00:36:49,320
bit more and also vaso vasoactive changes so that like where their hands look cold.  You

513
00:36:49,320 --> 00:36:53,400
mean yeah yeah look like they went into a cold room and everything turned blue for a

514
00:36:53,400 --> 00:36:57,120
couple seconds and then which is scary for a mother or father yeah it would look like

515
00:36:57,120 --> 00:37:02,480
your kids suffocating you know it through his hands or feet but in really in real life

516
00:37:02,480 --> 00:37:07,400
there's no known consequence when that happens it's just like a thing that's known to happen

517
00:37:07,400 --> 00:37:12,960
with these medicines and I think you hit on a great point so these are blood - this propranolol

518
00:37:12,960 --> 00:37:19,760
and so oral propranolol and topical timolol...topical by the way when we say topical what

519
00:37:19,760 --> 00:37:24,120
we're talking about is you do not give this to your baby's mouth.  You would be putting

520
00:37:24,120 --> 00:37:30,960
it directly on the skin and in fact just as a little interesting side note from what I've

521
00:37:30,960 --> 00:37:36,020
learned of topical timolol...It cannot be given - should never be given - orally because it's

522
00:37:36,020 --> 00:37:43,360
actually much stronger in terms of its potency than oral propranolol and for that

523
00:37:43,360 --> 00:37:48,080
reason I always tell my families who are using the topical you want to be very

524
00:37:48,080 --> 00:37:54,240
certain who's giving this medicine - not a child that's helping take care of the his baby brother

525
00:37:54,240 --> 00:38:01,300
or sister, not a mother-in-law who's visiting and forgets that this is not to be delivered

526
00:38:01,300 --> 00:38:05,080
into the baby's mouth with the little dropper.  This is going on the skin.  That's what we're

527
00:38:05,080 --> 00:38:10,160
talking about topical.  It's actually an eye drop as its original function was for glaucoma.

528
00:38:10,160 --> 00:38:16,080
Right yeah. Absolutely.  It lowers the blood pressure in a condition called glaucoma and

529
00:38:16,080 --> 00:38:21,920
that's the point so these are blood pressure lowering medicines being used in

530
00:38:21,920 --> 00:38:28,280
a population of kids with infantile hemangiomas who don't really normally have high blood

531
00:38:28,280 --> 00:38:33,720
pressure so all the side effects are directly related to taking this anti high blood pressure

532
00:38:33,720 --> 00:38:38,560
medicine when you don't need those medicines.  So like you said lowering your blood pressure

533
00:38:38,560 --> 00:38:44,020
that's the probably the biggest risk you can cause someone to to to drop their blood pressure

534
00:38:44,020 --> 00:38:49,720
dangerously low. You can die from that. You can drop their blood sugar levels dangerously

535
00:38:49,720 --> 00:38:51,160
low.  You can die from that.

536
00:38:51,160 --> 00:38:53,160
You can get a seizure too.

537
00:38:53,160 --> 00:38:59,040
Seizures yeah so it's not to be taken lightly.  But at the end of the

538
00:38:59,040 --> 00:39:03,080
day and I used to have it when we actually I don't know if you remember but when this

539
00:39:03,080 --> 00:39:08,760
protocol first came out when we were fellows we had to call consults on the Cardiology

540
00:39:08,760 --> 00:39:13,760
team - the Pediatric Cardiology team - every patient that we wanted to start this medicine on and

541
00:39:13,760 --> 00:39:19,720
I had for a while I had it with me I think when I left Rrady Children's - I think it died

542
00:39:19,720 --> 00:39:25,560
in the ethos - but I had a letter from one of the cardiologists there that said, "Please, please...

543
00:39:25,560 --> 00:39:32,920
for the love of God stop calling me.  The doses that you guys are maxing out at are not

544
00:39:32,920 --> 00:39:38,760
even the doses that we usually start our kids on when they do have high blood pressure!"  So

545
00:39:38,760 --> 00:39:43,280
probably we were making a bigger deal of it but truthfully that was not something that

546
00:39:43,280 --> 00:39:50,480
we were experts at back then.  Now, thankfully, we've got what 12, 13 years of experience using

547
00:39:50,480 --> 00:39:57,040
this medicine and I actually heard for the first time in our area a pediatrician was

548
00:39:57,040 --> 00:40:02,760
managing this himself or herself without a dermatologist so it's sort of it's

549
00:40:02,760 --> 00:40:07,080
starting to trickle down and I think people are less afraid and realize like with some

550
00:40:07,080 --> 00:40:13,640
good prep time and preparation for the families you can avoid 98% of these

551
00:40:13,640 --> 00:40:18,360
issues.  Some are going to happen no matter what but the hypoglycemia...what do you

552
00:40:18,360 --> 00:40:22,360
tell your patients to do to avoid hypoglycemia?  You must always give

553
00:40:22,360 --> 00:40:29,200
the medicine with a feed so what I do is I have the mom maybe give a half feed then give

554
00:40:29,200 --> 00:40:32,420
the medicine then finish and the reason I don't do a full feed is sometimes they're

555
00:40:32,420 --> 00:40:37,920
so full they don't even want to take the medicine.  And then the other thing I caution is if a

556
00:40:37,920 --> 00:40:43,560
baby is ill like let's say they have the flu - they're vomiting or they're not stooling normally,

557
00:40:43,560 --> 00:40:48,160
or just not feeling good for whatever reason - I have the family skip the dose that

558
00:40:48,160 --> 00:40:54,000
day. There's no harm to the hemangioma and taking a break for a day or two and it's not

559
00:40:54,000 --> 00:41:00,840
worth the risk.  Very similarly I always counsel the families like look - let's say little Mary

560
00:41:00,840 --> 00:41:05,680
or a little Johnny is sitting there. You're getting ready to dose otherwise looks totally

561
00:41:05,680 --> 00:41:12,320
healthy.  You give the dose of propranolol and we almost exclusively use and it's one

562
00:41:12,320 --> 00:41:18,880
of the only times we actually do almost exclusively use the brand name oral Hemangeol, which is

563
00:41:18,880 --> 00:41:25,940
a very specifically studied form of generic propranolol.  It's the same medicine but it

564
00:41:25,940 --> 00:41:32,240
comes in a "twice a day" formulation rather than a three times a day.  There's no alcohol,

565
00:41:32,240 --> 00:41:38,200
which I think is a big plus for dosing babies, and it's flavored.  It's supposed to be strawberry

566
00:41:38,200 --> 00:41:43,160
vanilla. I never tried it myself but it's pink and my point here is when you give this to

567
00:41:43,160 --> 00:41:48,060
the baby little Johnny, little Mary sitting there you give them the two mLs or whatever

568
00:41:48,060 --> 00:41:52,760
their dose is supposed to be...They look at you. They smile and they puke it right back up

569
00:41:52,760 --> 00:41:58,680
onto the floor - what's clearly six mLs,  three times as much! What do you do? and  I'll

570
00:41:58,680 --> 00:42:04,640
just pause and I just say what would you guys do and usually someone in the room says do

571
00:42:04,640 --> 00:42:10,520
nothing. That's the right answer!  Don't give the dose again.  Don't double up on it.  You assume

572
00:42:10,520 --> 00:42:15,440
little Johnny, little Mary got the entire dose into their brains and you're not going to

573
00:42:15,440 --> 00:42:19,960
risk giving them a second dose right then and there. Just wait.  If you miss one dose - to

574
00:42:19,960 --> 00:42:24,600
your point, Dr. Piggott - who cares?  It's not a matter of life and death.  And

575
00:42:24,600 --> 00:42:32,800
I also - one of the other things - especially in families with multiple caregivers I I remind

576
00:42:32,800 --> 00:42:39,440
them how easy it is to forget that maybe dad gave it in the morning and mom doesn't realize

577
00:42:39,440 --> 00:42:43,920
it and gives another dose, so I I encourage them to have like a little calendar on the

578
00:42:43,920 --> 00:42:48,480
wall where it's checked off so you know that the dose was given or I usually or I'll say

579
00:42:48,480 --> 00:42:53,280
you have just one person be in charge of giving this dose.  That's brilliant!  Yeah I like that

580
00:42:53,280 --> 00:42:57,760
a lot.  That has happened.  Usually for these patients I'm giving them my personal cell

581
00:42:57,760 --> 00:43:01,840
phones letting them know hey if you have any questions especially in the beginning but

582
00:43:01,840 --> 00:43:06,800
two or three months in they're experts.  But there are - and I did one Saturday get a call

583
00:43:06,800 --> 00:43:12,080
from mom that dad had doubled the dose by not remembering that mom had done it so

584
00:43:12,080 --> 00:43:17,440
it's kind of scary but at the end of the day baby's fine, healthy, eating, give him a couple extra

585
00:43:17,440 --> 00:43:22,800
rounds of milk and don't give the next dose and you're fine.  So the other thing to

586
00:43:22,800 --> 00:43:27,520
remember is we're not starting this medicine "cold turkey," right?  We're not going right up

587
00:43:27,520 --> 00:43:32,200
to a dose that we would need to see clinical effect on these hemangiomas at least

588
00:43:32,200 --> 00:43:36,120
we're not I don't know if you're still doing the ramp up but...Absolutely!  You are? So good.

589
00:43:36,120 --> 00:43:42,680
So the first week or so is a test dose that's not even supposed to do anything to the hemangiomas.

590
00:43:42,680 --> 00:43:47,640
It's just supposed to be there to see how the kid's reacting to the medicine and then

591
00:43:47,640 --> 00:43:52,600
once you establish that the heart rate and the blood pressure are still within healthy

592
00:43:52,600 --> 00:43:58,040
limits then you actually give the second dose which you could expect to see some clinical

593
00:43:58,040 --> 00:44:03,280
effect.  If you don't there's even a third level which I sometimes don't even go up to

594
00:44:03,280 --> 00:44:06,640
if I'm getting good effect at the second level I don't even go up to the third level. How

595
00:44:06,640 --> 00:44:13,680
about you?  Agreed and what we sometimes do if the baby is especially in let's say it's

596
00:44:13,680 --> 00:44:20,400
a newborn like two weeks old rapidly growing you know PHACE syndrome type baby after we've

597
00:44:20,400 --> 00:44:24,440
done the workup we there are cases where we even send them to the hospital to be

598
00:44:24,440 --> 00:44:29,760
admitted for monitoring when they're started on the Hemangeol or the generic

599
00:44:29,760 --> 00:44:36,080
propranol.  Yeah and you know you and I were were just featured in that Practical Dermatology

600
00:44:36,080 --> 00:44:40,120
roundtable that we got to do together, which is kind of cool but we talked a little bit

601
00:44:40,120 --> 00:44:44,080
about how long these kids are on propranolol - when you start to take them off.  What's

602
00:44:44,080 --> 00:44:51,960
your approach there?  Well it totally depends on on the case.  What I try to do clinically

603
00:44:51,960 --> 00:45:00,280
is when I see that the hemangioma is starting to involute on its own I might either leave

604
00:45:00,280 --> 00:45:05,440
the baby at the same mLs and not adjust the dose for weight gain or sometimes I even go

605
00:45:05,440 --> 00:45:11,560
quicker.  There's actually an article published in the last year or two that suggested approximately

606
00:45:11,560 --> 00:45:17,360
thirteen months or so is when a lot of people start to taper but I actually think I've done

607
00:45:17,360 --> 00:45:23,120
it younger than that. Okay I tend to maybe even on the other side of things push a little

608
00:45:23,120 --> 00:45:27,760
closer to a year year and a half especially depending on what anatomical area it's at

609
00:45:27,760 --> 00:45:33,120
but I think for the purposes of this discussion - if anybody's out there and wondering if A...

610
00:45:33,120 --> 00:45:38,200
their child has an infantile hemangioma and B are they at risk for any of these problems

611
00:45:38,200 --> 00:45:44,640
the the real key point of this discussion is don't allow yourself or your family to be

612
00:45:44,640 --> 00:45:49,600
told you'll get in to see the specialist in six months, nine months.  Literally you know

613
00:45:49,600 --> 00:45:53,800
if you have to you insist with the pediatrician, you insist with your family medicine doctor,

614
00:45:53,800 --> 00:45:58,440
your primary care doctor whoever that may be...You say, "Listen I I need to get this child

615
00:45:58,440 --> 00:46:03,000
in to make sure this is okay!" and then you reach out to the dermatologist or if you're

616
00:46:03,000 --> 00:46:08,120
lucky enough to have a board certified pediatric dermatologist.  There's not a lot of us out

617
00:46:08,120 --> 00:46:13,560
there but they're enough that most of the time we are tuned in and our staffs tuned

618
00:46:13,560 --> 00:46:18,080
in to know, hey,  this could be a real emergency and we make every effort to get these kids

619
00:46:18,080 --> 00:46:23,280
in and be seen quickly.  So, with that I think for the last portion of the show we'll switch

620
00:46:23,280 --> 00:46:28,240
gears just a little bit.  We're still talking about red birthmarks but I want to

621
00:46:28,240 --> 00:46:34,440
focus, Dr. Piggott, on port wine birthmarks.  We know these things also go by a couple of

622
00:46:34,440 --> 00:46:41,600
names like capillary malformations or the old one "nevus flammeus." These are another

623
00:46:41,600 --> 00:46:48,240
kind of birthmark that kids have.  We see them not nearly as frequently as hemangiomas.  Hemangiomas

624
00:46:48,240 --> 00:46:54,600
can pop up in about 5% of the population; port wine birthmarks pop up in only maybe

625
00:46:54,600 --> 00:46:59,960
one to two percent of the population at most, so it's rarer but we do see these things

626
00:46:59,960 --> 00:47:05,960
and I'll ask you how, what's your approach to differentiating port wine birthmarks - by

627
00:47:05,960 --> 00:47:10,120
the way, they used to be called "port wine stains" if you're confused listening.  We're trying

628
00:47:10,120 --> 00:47:14,880
to get away from using that word "stain" because it sounds negative and this is a kid's

629
00:47:14,880 --> 00:47:20,480
birthmark on a child and half the goal here is to teach them to be comfortable in

630
00:47:20,480 --> 00:47:24,320
their own skin so to speak.  So calling something a "stain" isn't really the nicest thing so

631
00:47:24,320 --> 00:47:28,840
if you see that there's an old phrasing of "port wine stain" yes we're talking about the

632
00:47:28,840 --> 00:47:33,560
same thing, but what's your approach, Dr. Piggott, to differentiating these things?

633
00:47:33,560 --> 00:47:37,600
So the most important thing is to get a history from the family as to whether or not it was

634
00:47:37,600 --> 00:47:43,280
present at birth.  If it was not present at birth it is unlikely to be a port

635
00:47:43,280 --> 00:47:48,960
wine. When they're young they can even look a little bit pink but later in life they look

636
00:47:48,960 --> 00:47:54,840
red.  They don't hurt the baby - the baby's not bothered by them and in babies

637
00:47:54,840 --> 00:47:59,720
they're flat.  They don't usually have a texture.  They don't have that strawberry look of a

638
00:47:59,720 --> 00:48:05,880
hemangioma and if you're seeing a child later in life the parents will give you also a

639
00:48:05,880 --> 00:48:10,760
history that it kind of grows proportional to the baby's growth.  It doesn't grow out of

640
00:48:10,760 --> 00:48:15,660
proportion.  It doesn't spread to other parts of the body. I think that's a really critical

641
00:48:15,660 --> 00:48:20,600
point for the listeners...So, these these port wine birthmarks are present at birth, you're

642
00:48:20,600 --> 00:48:24,960
saying, and they're totally flat so the first clue that maybe you're not talking

643
00:48:24,960 --> 00:48:31,120
about a port wine birthmark would be that if all of a sudden the area started to

644
00:48:31,120 --> 00:48:36,600
raise.  That would really suggest at least to me maybe we're talking about a hemangioma,

645
00:48:36,600 --> 00:48:41,800
but specifically a segmental hemangioma - one of these larger ones which not to put the

646
00:48:41,800 --> 00:48:46,440
fear of God into anybody but those are really an emergency in the sense that they can be

647
00:48:46,440 --> 00:48:50,920
related to those other syndromes that you mentioned.  But port wine birthmarks themselves -

648
00:48:50,920 --> 00:48:57,040
they will tend to stay flat.  You might see two weeks in they might get a little

649
00:48:57,040 --> 00:49:01,160
lighter.  That's sort of the physiological changes that happen in those new babies and

650
00:49:01,160 --> 00:49:05,800
then they go right back to being red.  They also don't as far as I've experienced they

651
00:49:05,800 --> 00:49:11,760
don't fade.  Yes and one of the things that you can confuse it with...

652
00:49:11,760 --> 00:49:17,880
there's something called a "nevus simplex" which is they have all sorts of names for them:  angel's

653
00:49:17,880 --> 00:49:25,280
kiss," "stork bite," "salmon patch," which are other red birthmarks that are flat at birth, present

654
00:49:25,280 --> 00:49:31,960
at birth, and they can be very commonly located on for example the eyelids. They can be in

655
00:49:31,960 --> 00:49:36,760
your glabella which is the lower part of your forehead almost in a v-shape and those are

656
00:49:36,760 --> 00:49:41,160
different in that they're present at birth but very commonly fade over the first year

657
00:49:41,160 --> 00:49:46,160
of life and in most cases even go away completely where with the exception being the one at

658
00:49:46,160 --> 00:49:51,000
the back of the neck of course the stork bite which is different from a port

659
00:49:51,000 --> 00:49:57,200
wine birthmark, which will not really fade over time and quite conversely now it happens

660
00:49:57,200 --> 00:50:03,580
long long time not when the child is a baby or even a teenager but when you're talking

661
00:50:03,580 --> 00:50:08,520
the patient becomes an adult we see port wine birthmarks not only not fade but we see them

662
00:50:08,520 --> 00:50:13,240
actually turn darker though they'll assume a sort of a purplish hue which is where they

663
00:50:13,240 --> 00:50:19,560
get the term "port wine" to begin with and then they can also develop blebs -these little bumps

664
00:50:19,560 --> 00:50:24,760
and sort of thickening within them.  Do you see that a lot?  Yeah they are and again

665
00:50:24,760 --> 00:50:30,340
this is usually not until they're teenagers or even later they thicken almost like

666
00:50:30,340 --> 00:50:35,160
a leathery textured feel but you will never see this in a child so when you're trying

667
00:50:35,160 --> 00:50:39,800
to figure out if it's this versus another type of birthmark you wouldn't see this at

668
00:50:39,800 --> 00:50:43,640
a young age.  That's a great point.  Yeah you would expect to see

669
00:50:43,640 --> 00:50:49,000
that maybe 40, 50, 60 years out.  Now the good news is, you know, jumping to the punchline

670
00:50:49,000 --> 00:50:52,560
of what to do about these things - we're not seeing a lot of those patients who are 50

671
00:50:52,560 --> 00:50:57,280
or 60 because we've got some amazing treatment options but before we get into the management

672
00:50:57,280 --> 00:51:03,920
approach what's your current understanding of what's driving these birthmarks, these

673
00:51:03,920 --> 00:51:10,360
port wine birthmarks?  There's actually a gene that we think might have a somatic mutation...

674
00:51:10,360 --> 00:51:17,740
it's called the GNAQ gene which we think might be associated with some of the facial port

675
00:51:17,740 --> 00:51:25,200
wine stains especially those that develop into something called Sturge Weber but what

676
00:51:25,200 --> 00:51:32,000
What is your opinion?  No I think that's pretty pretty well studied now.  Most of these

677
00:51:32,000 --> 00:51:36,360
birthmarks I think there's a couple rare cases where the kind that are

678
00:51:36,360 --> 00:51:41,400
being passed from one family member down to another has been associated with RASA1

679
00:51:41,400 --> 00:51:47,260
mutations but by far when you do any of these sort of genetic studies

680
00:51:47,260 --> 00:51:52,480
on the tissue that constitutes these birthmarks you're seeing the GNAQ mutation,

681
00:51:52,480 --> 00:51:58,080
like you mentioned. It's very important to say though this is when you say somatic mutation

682
00:51:58,080 --> 00:52:02,880
this is not usually something that gets passed from mother or father to a baby.  This is something

683
00:52:02,880 --> 00:52:08,320
that's happening in the skin after the child was born and my limited understanding

684
00:52:08,320 --> 00:52:14,900
of the physiology or the pathophysiology of these is that the earlier that mutation

685
00:52:14,900 --> 00:52:18,640
happens it's usually more associated with some of the bigger problems.  What are some

686
00:52:18,640 --> 00:52:23,880
of the bigger problems that we see with port wine birthmarks?  So the most important one

687
00:52:23,880 --> 00:52:34,440
to identify early is a syndrome called Sturge-Weber syndrome and the sort of classic case is that

688
00:52:34,440 --> 00:52:44,040
baby is born with a large red port wine birthmark on the forehead-upper eyelid area and

689
00:52:44,040 --> 00:52:48,360
the reason this is very important is because this is actually we call it a neurocutaneous

690
00:52:48,360 --> 00:52:55,760
syndrome.  Not only does it have a facial port wine stain it can have leptomeningeal capillary

691
00:52:55,760 --> 00:53:01,160
or capillary venous malformations which is things in the brain and it can also have an

692
00:53:01,160 --> 00:53:06,920
increased risk of the baby having glaucoma.  Other rare things that the syndrome can have

693
00:53:06,920 --> 00:53:13,640
the baby can have epilepsy, encephalopathy, and hemiparesis so when you see a baby with

694
00:53:13,640 --> 00:53:20,160
a large hemangioma especially on the forehead sort of upper eyelid eyebrow area we often

695
00:53:20,160 --> 00:53:27,040
do imaging such as an MRI to assess the brain and also we consult our pediatric ophthalmologist

696
00:53:27,040 --> 00:53:33,160
to assess for glaucoma for which early intervention is key to save the baby's vision.

697
00:53:33,160 --> 00:53:37,340
Yeah you got to really be an advocate for the patient there and those wait times for

698
00:53:37,340 --> 00:53:42,400
pediatric ophthalmology can be really long as well but most pediatric ophthalmologists

699
00:53:42,400 --> 00:53:45,480
that I've ever worked with will take these kids very quickly and make sure that they're

700
00:53:45,480 --> 00:53:46,480
okay.

701
00:53:46,480 --> 00:53:51,080
The good news is there's treatment, which you are one of the top experts in.

702
00:53:51,080 --> 00:53:53,000
In treating these things...

703
00:53:53,000 --> 00:53:55,360
Yes, the laser..

704
00:53:55,360 --> 00:54:03,400
Well, thank you. I do enjoy it.  It's very rewarding to be able to have a piece of machinery - this

705
00:54:03,400 --> 00:54:10,000
pulse dial laser is what we're talking about - here that will take a birthmark like this

706
00:54:10,000 --> 00:54:16,360
and not with infrequent amount of treatments - you need, you're talking 10 15 maybe even 15

707
00:54:16,360 --> 00:54:22,240
to 20 treatments - but you can almost assuredly take these birthmarks from what

708
00:54:22,240 --> 00:54:28,120
they look like and reduce the amount of pink and red in them by about 75 to 85 percent

709
00:54:28,120 --> 00:54:34,080
with really not much difficulty and then going that extra little 10 to 15

710
00:54:34,080 --> 00:54:39,360
percent is really kind of where maybe the art is, but we've been able to do amazing

711
00:54:39,360 --> 00:54:43,440
things with this and that's - actually it's funny that you brought that up because I was

712
00:54:43,440 --> 00:54:47,640
able to train with one of your colleagues Vic Ross who's out there at Scripps and

713
00:54:47,640 --> 00:54:54,100
he was very generous in teaching me what to do and how to do it so, yeah, we're pretty thrilled

714
00:54:54,100 --> 00:54:57,720
to be able to have that technology and it hasn't changed much in 20 years. I mean

715
00:54:57,720 --> 00:55:00,540
it's really been the go-to machine.

716
00:55:00,540 --> 00:55:03,040
What does a laser do, Dr. Krakowski, to the blood vessel?

717
00:55:03,040 --> 00:55:08,400
Yeah, so it targets the blood -  specifically the hemoglobin within the blood 

718
00:55:08,400 --> 00:55:17,280
vessels - and the laser for a quick description is basically superheating very quickly

719
00:55:17,280 --> 00:55:23,040
and very focusedly the chromophore - this hemoglobin inside the blood vessel - which

720
00:55:23,040 --> 00:55:28,160
acts then to fry the blood vessel.  It's cauterizing - if you're familiar with that term - it's cauterizing

721
00:55:28,160 --> 00:55:33,920
the blood vessels from inside the blood vessels, which knocks them out and and keep the blood

722
00:55:33,920 --> 00:55:37,200
from flowing within them.

723
00:55:37,200 --> 00:55:40,320
The problem is those blood vessels tend to want to grow back and you have to keep going

724
00:55:40,320 --> 00:55:44,720
back in and knock them down, but but we've gotten very good at doing that and now there's

725
00:55:44,720 --> 00:55:51,280
even some modalities where we're treating much like PDT photodynamic

726
00:55:51,280 --> 00:55:58,040
therapy - we're looking at taking a medicine infusing it into the patient's bloodstream - 

727
00:55:58,040 --> 00:56:03,480
this is preferentially picked up by a port wine birthmark because of the extravascular

728
00:56:03,480 --> 00:56:08,360
pressure that's there and then taking a light source from outside and shining it onto the

729
00:56:08,360 --> 00:56:13,720
birthmark from the outside and you're basically cooking this birthmark from within so

730
00:56:13,720 --> 00:56:18,920
it's kind of a neat time to be involved with port wine birthmarks and being a part

731
00:56:18,920 --> 00:56:25,280
of that team but at the end of the day you have to really first make the diagnosis of

732
00:56:25,280 --> 00:56:32,000
what you're dealing with.  And I think in today's show what we saw was not all red is either

733
00:56:32,000 --> 00:56:36,520
a port wine or a hemangioma.  There are a lot of other things that these could be.  I

734
00:56:36,520 --> 00:56:41,040
think that really speaks to the value of having a good medical team caring for your

735
00:56:41,040 --> 00:56:46,760
child - having great access to a team that has the expertise to be able to differentiate

736
00:56:46,760 --> 00:56:51,040
between these different conditions and thankfully there's people out there like Dr. Caroline

737
00:56:51,040 --> 00:56:56,920
Piggott at Scripps and my pediatric dermatology colleagues who've devoted their entire lives

738
00:56:56,920 --> 00:57:03,360
to doing just that.  So with that, Dr. Piggott, thank you! I can't believe it's our first

739
00:57:03,360 --> 00:57:07,640
show together and we've been able to finally get this to work but it was really fun.

740
00:57:07,640 --> 00:57:09,600
Thank you so much for having me..

741
00:57:09,600 --> 00:57:16,320
All right, we will see you soon.

742
00:57:16,320 --> 00:57:20,760
Thanks for tuning in to this episode of the Don't Be Rash Pediatric Dermatology podcast.

743
00:57:20,760 --> 00:57:22,760
I'm your host Dr. Andrew Krakowski.

744
00:57:22,760 --> 00:57:26,880
Don't forget to subscribe to our show on your favorite podcast platform and check out 

745
00:57:26,880 --> 00:57:29,920
DontBeRash.org for more information.

746
00:57:29,920 --> 00:57:34,640
A special thank you to our nonprofit sponsor, the St. Luke's University Health Network, for

747
00:57:34,640 --> 00:57:36,440
making this episode possible.

748
00:57:36,440 --> 00:57:57,480
Until next time remember:  Keep calm and don't be rash!