Universidad Central de Venezuela Hospital Universitario de Caracas Servicio de Dermatologa y Sifilografa

Novedades en Dermatologia. Dermatologa Peditrica 1/4

Dr. Francisco Gonzlez

Hemangiomas

Pain Management for Ulcerated Infantile Hemangiomas.

Megan Strand, M.D., Aimee C. Smidt, M.D.
Pediatric Dermatology Vol. 29 No. 1 124126, 2012

Pain Management for Ulcerated Infantile Hemangiomas.

Abstract:
Perioral ulcerated hemangiomas in infants can present a therapeutic challenge to clinicians, especially when associated with severe pain and difficulty feeding.
Topical and oral pain medications can be beneficial, but feeding difficulties may still occur while awaiting healing of the ulceracin with the use of systemic or topical agents. We present a case of an infant with an ulcerated lip hemangioma treated with an overthe-counter topical sealant in combinacin with systemic corticosteroid therapy who showed dramatic improvement in pain and tolerance to feeding, resulting in healing of the ulceration.

Pain Management for Ulcerated Infantile Hemangiomas.

Ulceracin en HI Infantil : 513% . Dolor, Infeccin, Cicatrices, Falta de Apetito y Anemia Labio, Cuello y Area Perineal.

Pain Management for Ulcerated Infantile Hemangiomas.

7 Semanas :

Prednisolona : 3 mg/kg/d.
Tpico : Metronidazole + Mupirocin 9 Semanas : Peor + Acetaminophen con Codeine Oral Orabase

Pain Management for Ulcerated Infantile Hemangiomas.

Orabase
Orabase : over the counter Pasta Seca y Sellador Composicin : Activa : benzocaine 20% Inactiva : cellulose gum, flavor, pectin, plasticized hydrocarbon gel, and tragacanto gum. Efectos Adversos : Dermatitis Contacto. Metahemoglobinemia Adjuvante : Control del dolor local en HUL Areas Anatomicamente Difciles : Labios

Pain Management for Ulcerated Infantile Hemangiomas

3 mes

4 mes

5 mes

6 mes

Pain Management for Ulcerated Infantile Hemangiomas.

Conclusiones
Orabase : Eficaz en HIUL
Adjuvante : Control del dolor local en HUL Areas Anatomicamente difciles : Labios

Efectos Adversos : Dermatitis Contacto. Metahemoglobinemia ( muy raro) < 6 meses : NADH-dependiente metahb. reductasa

Topical Propranolol Therapy for Infantile Hemangiomas Karin Kunzi-Rapp, M.D.*

Pediatric Dermatology Vol. 29 No. 2 154159, 2012

Topical Propranolol Therapy for Infantile Hemangiomas

Eficacia de Propranolol 1% en Ungento en HSI

Ambulatorio

45 nios con 65 hemangiomas

Grupo I (39) : menor 6 meses / Grupo II: (6) : 7-33 meses
2mm

Propranolol 1% en Ungento Hidroflico Tpica BID. 2 IH Ulcerados : flash-lamp pulsed-dye laser + Propanolol

Topical Propranolol Therapy for Infantile Hemangiomas

Grupo I (39) : 7 pretrminos

Induce regresin en 59% No crecen en 26%
No respuesta proliferacin subcutneo en 15% Propanolol oral

No Efectos Adversos : Tpicos ni Sistmicos

Pretrmino ( 27 + 5)

14 das

2 meses

4 meses

Topical Propranolol Therapy for Infantile Hemangiomas

Grupo II (6)
HSI no cambiaba Respuesta 20 - 3er mes Mejora 100 %
Persiste 90 mes

14 meses (No)

19 meses (No)

3 meses post

2.5 mm 10 Semanas

2.0 mm 17 d. post

2 mes. post

1.9 mm

6 mes. post

Topical Propranolol Therapy for Infantile Hemangiomas Comparan Eficacia Vs Efectos Adversos

Corticoides, Imiquimod, Timolol

Intervencin Temprana en Fase Proliferativa

Induce regresin o Estabiliza en 85% a los 6 mes. Eficaz en Pretrminos de Bajo Peso Eficaz mas all de la Fase Proliferativa

Topical Propranolol Therapy for Infantile Hemangiomas Mecanismo de Accin Desconocido

El Beta Bloqueante tiene Accin Transdrmica

Requiere Penetracin Vehculo

10.4% - 36.6% atraviesa la piel

4.116.1% : Sangre Irritacin : Acumulativa(Parches en Oclusin en guinea pigs ) No : Sensibilizacin, Fototoxicidad, Fotosensibilizacin Terpenos Mejoran Penetracin por Disrupcin Barrera

Topical Propranolol Therapy for Infantile Hemangiomas. Conclusiones Eficaz en HSI / Aplicacin BID Tpicamente Acumula Cerca Pared Capilares / Sin Cambios Metablicos Alta Concentracin Local en Capilares del Hemangioma Baja Concentracin Sistmica

Investigar Penetracin Transdrmica del Propanolol Tpico

Evaluar la Optima Concentracin Propanolol Tpico y

Mejorar Formulacin Estudios Randomizados

Dermatitis

Atpica

Wet-Wrap Treatment in Children with Atopic

Dermatitis: A Practical Guideline

Arjan C. A. Devillers, M.D., Ph.D.,* and Arnold P. Oranje, M.D., Ph.D.

Pediatric Dermatology Vol. 29 No. 1 2427, 2012

Wet -Wrap dressings for the treatment of atopic eczema in children. Harper J, Goodtear H. Br J Dermatol 1991; 125(6) :604.

Vendajes Humedos con Furoato de Mometasona vs Prednicarbato en lactantes con dermatitis atopica severa. Gonzalez Otero F, Saenz A. Dermatologa Venezolana, 1997; 35: 107-109

Wet-Wrap Treatment in Children with Atopic Dermatitis: A Practical Guideline

Treatment of children with severe atopic dermatitis (AD) can be especially challenging because several possible intervention treatments have (relative) contraindications in childhood. In recent years, wet-wrap

treatment (WWT) has been advocated as a relatively safe and

efficacious intervention in children with severe or refractory AD. The goal of this article is to provide a practical guideline as a starting point

for clinicians who are interested in using WWT in their own clinical
practice. We will address several practical issues surrounding the use of WWT by describing our own experiences, supplemented with data from the literature.

Wet-Wrap Treatment in Children with Atopic Dermatitis: A Practical Guideline.

Mtodo muy Utilizado Seguro y Eficaz en Pacientes con DAG Variacin en : Vendajes, Tiempo Oclusin, Droga y Perodo Objetivo : Proveer Gua Prctica Pacientes Selectos de Difcil Tratamiento

Otros : 2 Lnea de Tratamiento

6 mes a 11 a. SCORAD > 35

Wet-Wrap Treatment in Children with Atopic Dermatitis: A Practical Guideline. Summary

1. Tubifast Garments . Pijama 2. Fluticasone propionate 0.05% diluda : Petrolatum 20% cetomacrogol crema 3. Bao Tibio. Humedecer en Agua Tibia. 1/10 Cuerpo 1/20 Cara

4. 1a Capa Hmeda / 2a Capa Seca

5. Humedecer cada 2 3 horas. No en Noche 6. 3 a 24 h ( sugieren 244 h en hospitalizados ) ?

7. 2 to 14 das
8. Promedio 7 das

TABLE 2. Possible Adverse Events During an Intervention Treatment with Wet-Wrap Dressings and (Diluted) Topical Corticosteroids for a Maximum Period of 14 Days Adverse event
Discomfort, including chills and poor acceptance Folliculitis ( unguentos ) Refractory skin lesions on areas not covered Temporary systemic bioactivity of corticosteroids Cutaneous Pseudomonas aeruginosa infection Impetigo Herpetic infections , Mol, VPH Estras

Occurrence
Frequent ? Common NO Common NO Common NO Rare Rare Rare Rara

Wet-Wrap Dressings and (Diluted) Topical Corticosteroids

Key Points to Remember

1. Is an effective and relatively safe short term intervention treatment in children with severe AD. 2. Should only be used as a second line, short term intervention treatment in children with AD.

3. Is not to be used in < 6 months of age or in puberty ?

4. Applied once daily when used in a WWT.

5. Possible adverse events are usually mild and temporary in nature.