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Published for the period of May -2025
RESIDERM: A LAUNCHPAD FOR YOUNG DERMATOLOGY PROFESSIONALS
Dermatology continues to be one of the most soughtafter and competitive specialties in medicine today. With a strong academic foundation, dermatology residents are among the most intelligent, skilled, and capable minds in the field. When provided with the right opportunities early in their careers, they have the potential to achieve remarkable milestones.
RESIDERM is one such platform—designed to empower residents to express their ideas, share experiences, and grow without limitations. This initiative aims to support young dermatologists as they navigate the early stages of their professional journey, shaping both their personal identity and their contributions to the field.
We understand that dermatology can be an intricate and sometimes overwhelming subject for new residents. The goal of RESIDERM is to offer meaningful guidance and mentorship—helping residents make informed decisions that foster their growth and enhance the learning environment for peers, medical students, and the wider healthcare system.
In this issue, we feature valuable insights and advice from experienced faculty, designed to inspire and guide. We also bring you engaging clinical case discussions, including Infantile Hemangioma and Terra Firma-Forme Dermatosis: A Rare Presentation in Dermatology.
We hope you find this issue both enjoyable and enriching. Your journey in dermatology is just beginning, and we are excited to be a part of it.
We look forward to your contributions for the next edition.
Warm Regards,
Team RESIDERM
- Dom Daniel Executive Editor & Publisher
Terra Firma-Forme Dermatosis: A Rare Presentation in Dermatology –A Case Report
Dr. Deepali Sengar
3rd Year Resident (2024)
Department of Dermatology
Mahatma Gandhi Memorial (MGM) Medical College, Indore Madhya Pradesh
Dr. Akash Jaiswal
2nd Year Resident
Department of Dermatology
Mahatma Gandhi Memorial (MGM) Medical College, Indore Madhya Pradesh
Dr. Sanjay Khare
MD (Dermatology)
Head of Department
Department of Dermatology
Mahatma Gandhi Memorial (MGM) Medical College, Indore, Madhya Pradesh
A Case Report on Infantile Hemangioma
Dr. Disha Baxi
MBBS, MD, (FAM)
Consultant Dermatologist at Skintimacy Indore, Madhya Pradesh
Terra Firma-Forme Dermatosis: A Rare
Presentation in Dermatology – A Case Report
Terra Firma-Forme Dermatosis: A Rare Presentation in Dermatology –A Case Report
Dr. Deepali Sengar
3rd Year Resident (2024)
Department of Dermatology
Mahatma Gandhi Memorial (MGM) Medical College, Indore Madhya Pradesh
Dr. Akash Jaiswal
2nd Year Resident
Department of Dermatology
Mahatma Gandhi Memorial (MGM) Medical College, Indore Madhya Pradesh
Dr. Sanjay Khare
MD (Dermatology)
Head of Department
Department of Dermatology
Mahatma Gandhi Memorial (MGM) Medical College, Indore, Madhya Pradesh
Introduction
Terra firma-forme dermatosis is a benign skin disorder characterized by raised, dirty-appearing patches of skin. It is also known as Duncan’s dirty dermatosis, named after the dermatologist who first described it. The term "terra firma" is Latin for "dry land," reflecting the appearance of
affected areas resembling islands of dirty skin. This condition primarily affects children and adolescents, although its exact prevalence is uncertain due to limited epidemiological studies. It is typically asymptomatic, and many individuals may not seek medical attention for it.1 It is characterized by thickened,
brown-black papules and plaques that typically appear on the neck, trunk, face, and abdomen, including the umbilicus. These plaques may exhibit a papillomatous surface. The condition has been observed around surgical sites, such as after total knee replacement or median sternotomy, and in rare cases, it can present with extensive involvement over the chest, abdomen, and thighs.2 Despite their appearance, these areas are not actually dirty but appear so due to abnormal keratinization. It commonly occurs in areas of the body that experience friction or rubbing, such as the neck, trunk, or extremities.1 Terra firma-forme dermatosis is considered a disorder of keratinization characterized by abnormal and delayed maturation of skin cells. This condition involves prolonged adhesion between keratinocytes, leading to the retention of melanin, sebum, and microorganisms, which results in the formation of brown patches and thickened plaques. It is hypothesized that terra firma-forme dermatosis may represent a ‘forme fruste’(an atypical or incomplete manifestation of another condition) of confluent and reticulated papillomatosis of Gougerot and Carteaud.2
Physical factors influencing the development of terra firma-forme dermatosis (TFFD) include its occurrence near surgical wounds, poor hygiene in disabled individuals, and areas under jewelry, as well as over flexures. Prolonged sun exposure, xerosis, and accumulation of sweat also contribute to its pathogenesis.2 Additionally, genetic factors such as a disorder of delayed keratinization may explain the higher incidence in children aged 0 to 10 years, and although there is no racial predilection, mutations in the filaggrin gene play a minor role.2 Individuals suffering from terra firma-forme dermatosis (TFFD) often face significant challenges due to the persistent and conspicuous nature of the condition. The emotional and psychological burden of dealing with a visibly persistent dermatological issue can impact quality of life, contributing to feelings of embarrassment and isolation.2 Maintaining a balanced diet and adequate hydration is essential for overall skin health and can play a supportive role in managing Terra Firmaforme dermatosis (TFFD). In managing Terra Firma-forme dermatosis (TFFD), lifestyle
modifications, particularly in diet and hydration, play a supportive role. A diet rich in essential nutrients—such as vitamins A, C, E, and zinc—is beneficial for skin repair and overall function. Incorporating a variety of fruits, vegetables, lean proteins, and whole grains into the diet can enhance skin resilience and promote a healthy complexion. Staying well-hydrated by drinking ample water is also crucial, as it helps maintain skin moisture and elasticity, which is important for managing the dryness and flakiness associated with TFFD. While dietary changes alone cannot cure TFFD, they can significantly contribute to improved skin health and complement other treatment strategies, ultimately enhancing the quality of life for those affected by the condition.2
Case Report
A 14-year-old female patient presented with terra firmaforme dermatosis (TFFD), which had been persistent for the past 6 months. Upon physical examination, multiple discrete papules were observed in the pubic region. These papules were distinctively raised, with a brownish-black coloration and a rough texture. They were clustered
together, forming larger plaques. Notably, the patient maintained good hygiene practices, and the lesions showed no signs of inflammation, tenderness, or discharge. Given the clinical appearance and characteristic features of the lesions, a diagnosis of TFFD was confirmed. Dermoscopic examination further supported this diagnosis by revealing exaggerated skin markings and accentuated skin lines, which are typical findings in TFFD. To address the condition, treatment commenced with the topical application of 70% isopropyl alcohol. This approach is aimed at cleansing the
affected area by removing the accumulated debris that contributes to the lesions. TFFD usually responds very well to this treatment, with a complete resolution of symptoms and a low likelihood of recurrence. The patient and her family were reassured that TFFD is a benign and self-limiting condition. They were advised on the use of alcohol wipes to manage any potential recurrence of lesions, emphasizing that ongoing good hygiene can help prevent future episodes. This approach ensures that the patient is well-informed about managing her condition effectively.
Diagnosis
Terra firma-forme dermatosis is primarily a clinical diagnosis characterized by lesions
on any area of the body that cannot be removed with soap. Wiping affected areas with a pad soaked in 70% isopropyl
alcohol will completely remove the lesions and is simultaneously diagnostic and therapeutic.3, 4.
Dermoscopy of terra firmaforme dermatosis reveals characteristic surface features of the lesions, such as a rough, irregular texture and a gritty appearance. The examination may show areas of hyperpigmentation with a mottled or patchy brownish color, corresponding to the dirty or soil-like appearance observed clinically.3, 4 Additionally, large brown polygonal areas arranged in a mosaic-like pattern are often seen. Dermoscopy helps in visualizing these texture and color patterns, which are indicative of the condition, and can assist in distinguishing TFFD from other dermatological disorders. A skin biopsy is rarely performed in terra firma-forme dermatosis (TFFD), as the findings are mostly nonspecific, including papillomatosis, acanthosis, and orthohyperkeratosis. Occasionally, keratin whorls may be observed and can be somewhat specific for the diagnosis. While the biopsy provides valuable insights, especially in ruling out other potential diagnoses, it is most effective when correlated with
Figure 1: Brownish- black papules on pubic region
Before treatment
After treatment
clinical and dermoscopic findings. The biopsy may reveal histological features such as acanthosis, which, when combined with clinical and dermoscopic data, can help confirm the diagnosis. In cases where the diagnosis is uncertain or other skin conditions need to be excluded, a skin biopsy can be a useful tool in the diagnostic process, contributing to a comprehensive assessment and accurate diagnosis.3,4 Further testing is typically not necessary for terra firma-forme dermatosis, but laboratory tests for fungal infections may sometimes be performed to rule out conditions such as pityriasis versicolor. Laboratory tests, including fungal cultures, are used to exclude other conditions with similar presentations, such as dermatophyte infections. In terra firmaforme dermatosis, these tests are expected to be negative, confirming that the lesions are not due to a fungal etiology. While these tests do not diagnose TFFD directly, they assist in excluding other potential causes of the skin lesions, thereby supporting the clinical diagnosis.3, 4
Treatment
The main goal for
treating Terra firmaforme dermatosis is to effectively remove the characteristic dirtyappearing areas on the skin and restore normal skin appearance. This typically involves the use of gentle yet effective methods to exfoliate the hyperkeratotic patches and promote skin cleansing. Additionally, patient education regarding proper skin hygiene practices and the benign nature of the condition is essential. Isopropyl alcohol, when used as a wipe, is highly effective in thoroughly removing dirty-appearing areas from the skin. This antiseptic solution helps to clean and disinfect the skin, reducing the risk of infection before applying other treatments. It is particularly useful for preparing the skin and ensuring that subsequent topical applications are effective. Mild topical keratolytic agents, such as 5% salicylic acid in petrolatum ointment, are beneficial for managing extensive dermatological conditions. These agents work by gently exfoliating the skin, breaking down keratin, and removing dead skin cells. They are particularly useful for avoiding the need for aggressive rubbing of large
areas, which can cause irritation or damage.5
Chemical peels using 20% salicylic acid in alcohol are effective in rapidly resolving certain dermatological conditions. This treatment involves applying a solution that exfoliates the skin, removing the outer layers and promoting the growth of new, healthy skin. Salicylic acid peels are particularly useful for treating conditions like acne and hyperpigmentation, providing a more aggressive exfoliation compared to topical keratolytics.5
Topical antifungal agents, including clotrimazole, miconazole, and terbinafine, treat fungal infections like athlete's foot and ringworm by inhibiting fungal growth; they are typically applied directly to the affected area once or twice daily and are generally well-tolerated, though local irritation may occur.5 Topical steroids such as hydrocortisone, betamethasone, and clobetasol reduce inflammation, redness, and itching in conditions like eczema and psoriasis, requiring careful application and monitoring to avoid side effects like skin thinning. Urea
Terra Firma-Forme Dermatosis: A Rare
cream hydrates and softens excessively dry or thickened skin, helpful in ichthyosis or psoriasis, by breaking down and removing dead skin cells, though it may cause mild irritation.5
Scrub bathing with pumice involves gently exfoliating the skin to remove dead cells and improve texture, especially for keratosis pilaris and rough skin, but should be done with caution to avoid over-exfoliation and maintain hygiene.5 Emollients are essential for soothing and hydrating the skin, particularly in eczema or psoriasis, by restoring the skin barrier and preventing moisture loss.5 Keratolytics, such as salicylic acid, help exfoliate by breaking down keratin and removing dead cells, which is beneficial for acne and psoriasis but may cause dryness if overused.5 Alpha-hydroxy acids (AHAs), glycolic acid, an AHA derived from sugar cane, is renowned for its small molecular size, which allows it to penetrate the skin deeply. It works by breaking the bonds between dead skin cells on the surface, facilitating their removal through exfoliation.5 This process accelerates the turnover of skin cells, revealing fresher, more evenly pigmented skin underneath. Glycolic acid
also stimulates collagen production, which can improve skin texture and reduce the appearance of fine lines and wrinkles over time.5 Lactic acid, another AHA, is derived from milk and has a slightly larger molecular size compared to glycolic acid, which results in a gentler exfoliation. It works by dissolving the bonds between dead skin cells and promoting their shedding.
Lactic acid also helps to enhance the skin's moisture content by increasing its natural hydration levels, making it effective for improving skin texture and tone. Additionally, lactic acid can stimulate collagen synthesis, contributing to the reduction of fine lines and overall skin smoothness.5 Topicalretinoids, such as tretinoin and adapalene, promote cell turnover to treat acne and signs of aging but may cause initial irritation and require sun protection.5 For severe or resistant cases, CO2 laser treatment removes layers of skin to promote new growth and address deep acne scars or extensive hyperpigmentation.5 Each treatment is chosen based on the specific condition, its severity, and individual
needs, with proper adherence to protocols and professional guidance being crucial for optimal results and minimizing side effects.
Discussion
Terra firma-forme dermatosis (TFFD) is a recently characterized cutaneous pigmentation disorder. It is an acquired, idiopathic condition that presents with distinctive, abnormal skin pigmentation. TFFD is more prevalent than commonly recognized and is frequently misdiagnosed. Awareness of this condition is crucial to prevent unnecessary diagnostic investigations and to facilitate appropriate management. TFFD can significantly impact an individual’s quality of life. The visible nature of the condition can lead to self-consciousness and embarrassment, particularly if the pigmentation is on exposed areas of the body. This can affect social interactions and professional settings, where individuals may face undue scrutiny or judgment. Additionally, the condition's persistence despite........... attempts at cleaning or topical treatments can be frustrating and distressing. The psychological burden of managing a chronic,
visually conspicuous skin condition can lead to anxiety, low self-esteem, and social withdrawal.6
Psychosocial distress associated with Terra Firma-forme dermatosis (TFFD) often stems from its dirty appearance, which may be misinterpreted as poor personal hygiene.1 This can lead to significant psychiatric impacts, including emotional strain and stigma related to the condition’s appearance. Patients frequently experience heightened anxiety and depression due to the social implications and frustration with ineffective treatments.2 The persistent and resistant nature of TFFD can further intensify these psychological challenges, making effective management and support crucial for improving patient well-being. Several other dermatological conditions can mimic Terra Firmaforme dermatosis, and distinguishing them is crucial for accurate diagnosis and treatment.5 Dermatitis neglecta results from inadequate skin cleansing and responds to washing with soap and water. Acanthosis nigricans appears as velvety, symmetrically distributed lesions in intertriginous areas, often
linked to obesity, metabolic syndrome, or, less commonly, internal malignancies. Confluent and reticulated papillomatosis of Gougerot and Carteaud is characterized by brown papules that coalesce into plaques with a net-like periphery, and remains resistant to vigorous rubbing with alcohol. Atopic dirty neck is an acquired hyperpigmentation of the neck seen in individuals with atopic dermatitis, particularly in Asian populations. Symmetrical acrokeratoderma presents as dirt-like hyperkeratotic areas on the upper and lower limbs, notably the wrists, ankles, and dorsum of hands and feet. Seborrhoeic keratosis involves benign growths of keratinocytes that may resemble Terra Firmaforme dermatosis but do not vanish with alcohol rubbing.6 Other conditions to consider include pityriasis versicolor, which presents with discolored patches of skin, epidermal naevus, a congenital lesion with a warty surface, and postinflammatory ....... hyperpigmentation, which results from skin inflammation leading to darkened areas.6 Preventive measures for terra firmaforme dermatosis primarily
involve maintaining good skin hygiene and minimizing friction or rubbing on affected areas. Regular bathing and gentle exfoliation can help remove excess keratinized skin cells, reducing the appearance of dirty patches. Wearing loose-fitting clothing may also help prevent friction-induced lesions from forming. Since the condition is benign and asymptomatic, no specific preventive measures are typically required beyond basic skin care practices.5 Future treatment strategies may involve advancements in topical therapies, such as novel formulations and enhanced exfoliation techniques, including new chemical peels and improved keratolytics. Additionally, exploring systemic treatments and preventive measures could offer more comprehensive management options for TFFD, aiming to address the condition more effectively and improve patient outcomes.
Conclusion
Terra Firma-forme dermatosis (TFFD) poses a distinct dermatological challenge due to its resemblance to other conditions like dermatitis neglecta and seborrheic
Terra Firma-Forme Dermatosis: A Rare
keratosis. Compounded by significant psychosocial impacts, including stigma and emotional distress, accurate diagnosis and management are crucial. Recent research focuses on the condition's pathophysiology and its links to environmental factors and skin care practices. Future treatment advancements may include improved topical therapies, novel chemical peels, and systemic treatments, aiming to offer better management and address both physical and psychological aspects of TFFD.
References
1. Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol. 1987;123(5):567569.
2. Mohta A, Sarkar R, Narayan RV, Deoghare S, Arora A. Terra FirmaForme Dermatosis-More Than Just Dirty. Indian Dermatol Online J. 2023;15(1):99-104. Published 2023 Dec 22. doi:10.4103/idoj. idoj_424_23.
3. Stiube A, Jenni D, Wiederkehr L, Anzengruber F, Nobbe S. Terra Firme-Forme Dermatosis Diagnostic Sign and Treatment: A Case Report. Case Rep Dermatol. 2019;11(1):108112. Published 2019 Apr 23. doi:10.1159/000499897.
4. Gusdorf L, Cribier B. Dermatoseenterresèche :
aspects anatomo-cliniques [Clinicopathological aspects of terra firma-forme dermatosis]. Ann DermatolVenereol. 2016;143(67):446-452. doi:10.1016/j. annder.2016.02.023.
5. Chun SW, Lee SY, Kim JB, Choi HM, Ro BI, Cho HK. A Case of Terra Firma-Forme Dermatosis Treated with Salicylic Acid Alcohol Peeling. Ann Dermatol. 2017;29(1):83-85. doi:10.5021/ ad.2017.29.1.83.
6. Erkek E, Sahin S, Çetin ED, Sezer E. Terra firma-forme dermatosis. Indian J DermatolVenereolLeprol. 2012;78(3):358-360. doi:10.4103/0378-6323.95455
A Case Report on Infantile Hemangioma
Dr. Disha Baxi
MBBS, MD, (FAM)
Consultant Dermatologist at Skintimacy
Indore, Madhya Pradesh
Introduction
Infantile Hemangiomas (IH) represent the most prevalent benign tumors in infancy. It is characterized by benign neoplasms composed of proliferative and hyperplastic vascular endothelium, with varying presentations and courses.1 Their colloquial moniker "strawberry marks" derives from their distinct clinical appearance. The majority of hemangiomas are harmless vascular birthmarks that typically don't require treatment. However, about 10% can be problematic, causing tissue damage or interfering with organ function. Large lesions may distort tissue or cause ulceration, while even small ones can obstruct airways or affect vision. Multiple or extensive lesions, especially in the liver, can divert blood flow and lead to
heart failure. Additionally, the tumor's abnormal endothelial surface may cause clotting issues.2
Infantile hemangiomas are broadly categorized into superficial, deep, or mixed types based on the extent of soft tissue involvement. Deep infantile hemangiomas penetrate into the subcutaneous tissue, while superficial infantile hemangiomas affect only the skin surface, and mixed infantile hemangiomas display characteristics of both superficial and deep infantile hemangiomas. Furthermore, infantile hemangiomas are classified more specifically according to their anatomical distribution as focal, multifocal, segmental, or indeterminate. Focal infantile hemangiomas manifest as well-defined lesions originating from
A Case Report on Infantile Hemangioma
a central focal point and represent the most common type, accounting for 68% of infantile hemangiomas cases. Multifocal infantile hemangiomas are focal lesions affecting multiple anatomical sites. Segmental infantile hemangiomas involve extensive areas of skin in a plaque-like manner, following patterns associated with embryonal developmental units. Infantile hemangiomas that do not fit the criteria for focal or segmental classification are termed indeterminate and constitute 17% of cases.1 Infantile hemangiomas typically undergo rapid postnatal growth followed by slow involution, often resulting in complete regression. However, certain cases may pose life- or functionthreatening risks or be associated with structural congenital anomalies.3
The pathogenesis of infantile hemangioma remains challenging and not fully comprehended, with various theories proposed to explain its onset. Immunohistochemical ...... studies have confirmed the vascular nature of these tumors, demonstrating the presence of specific markers like CD31, von willebrand factor, VEGF,
and urokinase in endothelial cells. Dysfunctions in angiogenesis and vasculogenesis pathways, affected by genetic factors, hormonal changes, and placental abnormalities, are implicated in the formation of these tumors.2
The factors associated with an elevated risk and heightened occurrence of infantile hemangiomas include prematurity, multiple gestation, elderly primigravida, placenta previa and pre-eclampsia.4 It is predominantly observed among Caucasian infants at a rate of approximately 10%, IH exhibits a notable female predominance with a ratio of 3:1. The progression of infantile hemangioma can be elucidated by delineating its clinical stages, facilitating a comprehensive understanding of its natural course. These distinctive features aid in distinguishing infantile hemangioma from congenital hemangiomas, which manifest fully at birth without subsequent postnatal growth.5
A collaborative, multidisciplinary approach involving pediatricians, dermatologists, and vascular anomalies specialists is paramount for optimizing the management
of infantile hemangioma. Through an understanding of its complex pathogenesis and personalized treatment strategies, favorable longterm outcomes can be achieved for affected infants.
Clinical presentation
Infantile hemangiomas follow a distinct pattern of development, typically characterized by two main phases: proliferation and involution. Proliferation occurs during early infancy, with gradual regression starting around 1 year of age. Between these phases, there may be a temporary balance called the "plateau" phase, where some cells continue to proliferate while others undergo involution and apoptosis. The involution process can take several years and varies in duration.2
During the proliferative phase (up to 12 months of age), early signs may include localized blanching or redness of the skin. As endothelial cells multiply, the Infantile hemangiomas grow larger, become more elevated, and feel rubbery. This growth phase may also be marked by surrounding paleness and dilated veins, with occasional ulceration leading to pain and scarring.2
Infantile hemangiomas typically appear before 4 weeks of age and grow rapidly, with most reaching 80% of their size by 3 months and completing most of their growth by around 5 months. Deep infantile hemangiomas tend to develop later and persist longer than superficial ones.2 Involution typically begins between 6 and 12 months of age, with the majority of regression occurring before age 4. During this phase, Infantile hemangiomas flatten and shrink, often starting from the centre and spreading outward. Superficial lesions may also show a graying or clearing of the central area.2
Reddish pink patches:
Infantile hemangioma often start as faint red marks or patches on the skin. As they grow, they can become raised, firm, and more intensely red or purple in colour. Some may have a bluish tint due to underlying blood vessels.2
Ulceration and Bleeding:
Infantile hemangioma can sometimes lead to ulceration, where the overlying skin breaks down, leaving an open sore. This can occur due to the pressure exerted by the hemangioma on the skin
or as a result of trauma. Ulceration may cause pain, discomfort, and in some cases, bleeding.2
Feeding impairment:
Infants with infantile hemangioma, particularly those affecting the perioral region or airway, may experience feeding difficulties. Ulcerated lip infantile hemangiomas can cause pain, making it challenging for infants to latch onto a nipple.2
Airway Involvement and Obstruction:
Airway hemangioma may manifest with or without concurrent skin manifestations. Symptomatic obstructive airway hemangioma, such as supra- and subglottic lesions, typically exhibit a biphasic inspiratory and expiratory stridor that worsens progressively within the initial 6 to 12 weeks of life during the proliferation phase of the lesion. Infants affected by these hemangiomas may also quickly develop noisy breathing or a hoarse cry.2
It is important to note that the clinical presentation of infantile hemangiomas can be highly variable, and not all hemangiomas will exhibit the same features. Additionally, the natural
history of these lesions can also differ from one individual to another, with some spontaneously regressing without treatment while others may require intervention to manage complications or aesthetic concerns.
Case Report
A 9-month old healthy child presented with a large vascular plaque with crusting and bleeding over right temporal area of scalp, pre and post auricular area since birth with gradual increase in size over the months, the size was around 10×10cm. Diagnostic imaging via MRI brain with contrast revealed extracalvarial altered signal intensity lesions with tortuous voids and a dilated tortuous feeding artery entering the lesion, suggestive of a vascular malformation. Laboratory findings, including Random Blood Sugar (RBS), Serum Calcium, and Electrocardiogram (ECG), were within normal limits. Clinical diagnosis confirmed an infantile hemangioma. The treatment plan involved systemic medication, including Syrup Prednisolone sodium phosphate solution (10mg/5ml) in tapering dose for 10 days, Tab Propranolol
hydrochloride (10mg – 1 tablet dissolved in 5ml distilled water and was given twice daily) with monitoring of pulse, and Timolol drops (0.25%) 2 drops twice daily. Systemic medication effectively resolved the large hemangioma, preventing ulceration, bleeding, and oozing from the lesion. The patient is still under follow up since 4 months.
Figure 1: 1st visit showed a large vascular plaque with crusting and bleeding over right temporal area of scalp, pre and post auricular area.
Figure 2: MRI of brain showed lesion appearing hyper intense on T2
Figure 3: MRI of brain with contrast revealed post contrast enhancement
Figure 4: 2nd visit after start the treatment
Figure 5: 3rd visit after start the treatment
A Case Report on Infantile Hemangioma
Diagnosis
Diagnosis of most infantile hemangiomas is based on clinical evaluation. By meticulously observing features such as size, colour, texture, and location, clinicians can make accurate diagnoses and monitor changes over time. This process, often complemented by patient history and sometimes imaging studies, enables healthcare providers to develop tailored management plans suited to individual patient needs. Through systematic examination, clinicians can effectively evaluate hemangioma and address associated symptoms or complications for optimal patient care.5
In cases where deeper involvement is suspected, imaging modalities such as ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI) are recommended to ascertain the extent of the hemangioma beyond superficial changes.6 Ultrasonography typically reveals a well-defined highflow parenchymal mass with potential shunting. During the involution phase, areas of increased echogenicity indicative of fat replacement may become apparent within the lesions. Both gray scale and color Doppler ultrasonography are valuable for monitoring the response of IHs to medical therapy. Additionally, ultrasonography is effective as a first-line screening tool for patients with multifocal IHs to assess liver or visceral involvement, although MRI is preferred for evaluating complex or extensive visceral lesions.5 CT findings resemble those observed on MRI, including well-defined and avidly enhancing lesions during the proliferative phase and less pronounced enhancement during involution. MRI is essential for evaluating infantile hemangiomas, offering detailed anatomical insights without radiation exposure. It accurately delineates
lesion extent, assesses involvement of adjacent structures, and distinguishes infantile hemangiomas from other conditions. Particularly valuable for deep or complex lesions and those with potential visceral involvement, MRI reveals well-defined lesions with varying signal intensity on T1- and T2-weighted sequences. It aids in treatment monitoring and identifies complications like ulceration or compression.5 In rare cases where the diagnosis is uncertain or if there is suspicion of malignancy, a biopsy may be performed. During a biopsy, a small sample of tissue is removed from the lesion and examined under a microscope by a pathologist to confirm the diagnosis of hemangioma and rule out other possible causes.3
The management approach to infantile hemangioma encompasses a spectrum of interventions tailored to individual cases. While observation serves for small, asymptomatic lesions, prompt intervention may be warranted for rapidly growing or functionally compromising tumors. Treatment options include pharmacologic agents like propranolol or corticosteroids, laser
Figure 6: 4th visit showed better improvement with the reduction of crusting and bleeding
A Case Report on Infantile
therapy, surgical excision, and interventional radiologic procedures.6, 7, 8
Among the spectrum of hemangiomas, various differential diagnoses warrant consideration to ensure accurate diagnosis. These include congenital hemangiomas, pyogenic granulomas, kaposiform hemangioendotheliomas,.... tufted hemangiomas, venous malformations, capillary malformations such as port wine stains, macrocystic lymphatic malformations, and malignant tumors such as sarcomas, cutaneous neuroblastomas, or lymphomas. Each differential necessitates careful evaluation to differentiate and accurately diagnose the underlying condition.5
Treatment
The treatment options for infantile hemangiomas include:
a. Beta-Blockers: Oral
Propranolol is the most commonly used betablocker for the treatment of hemangiomas.3 It helps inhibit the growth of the blood vessels within the hemangioma, leading to shrinkage and resolution of the lesion. Propranolol is usually administered orally in a liquid formulation,
with dosing tailored to the patient's weight and response. Propranolol helps reduce the size and redness of the hemangioma.4 Close monitoring of vital signs, particularly heart rate and blood pressure, is required during treatment.6
b. Corticosteroids:
Systemic corticosteroids, such as prednisolone, may be prescribed for large or problematic hemangiomas. Corticosteroids help reduce inflammation and suppress the growth of the hemangioma.3 They are typically administered in tapering doses over several weeks, with close monitoring for side effects.6
c. Topical Timolol:.....
Timolol is a common topical treatment for infantile hemangiomas, showing safety and efficacy, especially for small and superficial infantile hemangiomas.5
d. Vincristine:.............
Vincristine, derived from plants, is a vinca alkaloid that interferes with mitosis by affecting microtubule formation. Its antiangiogenic properties stem from its ability to induce endothelial cell apoptosis and inhibit endothelial cell growth, migration, and capillary-like tube
formation. While primarily used in vascular lesions associated with kaposiform hemangioendothelioma..... (KHE) or tufted angiomas (TAs) linked to KasabachMerritt phenomenon (KMP), vincristine has also shown efficacy in managing life-threatening or function-threatening infantile hemangiomas affecting the airway, orbit, or liver. Administered weekly through a central catheter due to its vesicant nature.5
e. Interferon-α:...........
Interferon-α 2a........ and 2b, has been efficacious in treating infantile haemangiomas in children. It is administered subcutaneously, starting with an initial dose of 1 million IU/m2, which is gradually increased to 3 million IU daily over the first month of treatment. Throughout therapy, monitoring of neurologic status, white blood cell count, and liver function is essential. Treatment duration typically ranges from 2 to 12 months.5
f. Imiquimod: A 5% Imidazoquinoline topical agent, acts as an immuneresponse modifier by stimulating the innate immune system. It enhances cytokine production, including interferons (α, β, and γ), IL-10, IL-12, IL-18,
and tumor necrosis factor. These cytokines bolster cell-mediated immunity and induce apoptosis. Imiquimod's therapeutic effect on infantile hemangiomas may involve inhibition of angiogenesis by these cytokines. Additionally, it down regulates proangiogenic factors like bFGF and MMP-9 while upregulating endogenous angiogenesis inhibitors such as interferoninducible protein 10, tissue inhibitor of MMPs, and thrombospondins. Topical imiquimod application has demonstrated significant inhibition of tumor cellinduced angiogenesis in human keratinocyte models.5
2. Laser Therapy:
Lasers have become a keystone for treating various cutaneous lesions, including infantile hemangiomas, following the development of the theory of selective photothermolysis. The pulsed dye laser (PDL) stands as the most frequently utilized laser for managing infantile hemangiomas.5, 8
Another commonly employed laser for vascular lesion treatment is the Neodymium-Doped Yttrium Aluminium Garnet (ND laser) operating at mid-
infrared wavelengths (1064 nm), it corresponds to an additional infrared absorption peak of oxyhemoglobin around 1000 nm. With its ability to penetrate deeper (5–6 mm) compared to PDL (0.75–1 mm), it finds indication in treating deep or mixed hemangiomas, particularly when both laser types are combined. However, a notable drawback is the pain experienced during laser sessions.5, 8
3. Surgical Excision:
Surgical removal of the hemangioma may be considered for lesions that are large, disfiguring, or causing functional impairment.4, 6 It is typically reserved for hemangiomas that do not respond to other treatment modalities or pose a significant risk to the patient's health.6, 8 Close follow-up care is necessary to monitor for recurrence and ensure optimal wound healing.5, 8
4. Interventional.........
Inselect cases, interventional radiologic procedures such as embolization or sclerotherapy may be employed to treat hemangiomas.4 These techniques involve injecting
a substance into the blood vessels supplying the hemangioma to block blood flow and induce shrinkage.4 Interventional radiologic procedures are often reserved for complex or deep-seated hemangiomas that are difficult to treat by other means.6
Discussion
Infantile hemangioma, while not typically lifethreatening, can profoundly affect a patient's quality of life and mental well-being. Therefore, a comprehensive understanding of its occurrence, development, potential mechanisms, and treatment options is essential. Various risk factors have been identified, including low birth weight (LBW), preterm birth, female sex, Caucasian race, progesterone therapies, multiple gestations, and a family history of infantile hemangioma. Additionally, emerging research suggests associations with in vitro fertilization (IVF), advanced maternal age, placental anomalies and maternal tobacco use.9
Local hypoxia plays a pivotal role in infantile hemangioma development by suppressing the hypoxiainducible factor pathway (HIF-pathway), leading to dysregulated proliferation.
A Case Report on Infantile Hemangioma
Anemia during pregnancy exacerbates hypoxia, increasing the risk of infantile hemangioma development and complicating maternal and perinatal health. Studies have highlighted a significant correlation between maternal anemia and infantile hemangioma occurrence, emphasizing the importance of monitoring and managing maternal health during pregnancy.9
Infantile hemangiomas can be associated with a range of systemic syndromes, each presenting unique challenges in diagnosis and management. Among these syndromes, PHACE and LUMBAR syndrome stand out prominently. PHACE syndrome is characterized by a spectrum of anomalies including posterior fossa malformations, hemangiomas, arterial abnormalities, cardiac defects, and eye abnormalities.1 Maternal preeclampsia or placental defects often accompany this syndrome. Diagnosis typically involves a thorough clinical evaluation, including detailed assessment of cutaneous hemangiomas, neurological examination to detect any posterior fossa abnormalities, cardiac evaluation
for structural defects, and ophthalmological assessment for ocular anomalies.2
Conversely, LUMBAR syndrome presents with lower body hemangiomas, urogenital abnormalities, ulceration, myelopathy, bony deformities, anorectal malformations, and arterial anomalies. The diagnosis of LUMBAR syndrome necessitates meticulous examination, focusing on the localization of cutaneous hemangiomas, assessment of genitourinary and gastrointestinal systems for associated abnormalities, neurological evaluation for signs of myelopathy, and imaging studies to identify bony deformities or arterial anomalies.1
Additionally, other syndromes associated with infantile hemangiomas include PHACES syndrome (PHACE syndrome plus sternal defects or supraumbilical raphe), SACRAL syndrome (spinal dysraphism, anogenital, cutaneous, renal, and urologic anomalies, associated with an infantile hemangiomas on the back), and PELVIS syndrome (perineal hemangioma, external
genital malformations, lipomyelomeningocele,...... vesicorenal abnormalities, imperforate anus, and skin tag).
Clinical examination plays a crucial role in assessing hemangiomas, guiding diagnosis, and monitoring progression. Patient medication history and sometimes imaging studies, aids in accurate diagnosis. Treatment modalities for infantile hemangiomas primarily target morbidity prevention and complication management during the proliferative phase. Systemic medical interventions are advised for preempting complications, especially in anatomically sensitive regions or instances of rapid growth. Corticosteroids, laser therapy,8 and surgical procedures are viable options throughout both the proliferative and involution stages.3 Surgery frequently becomes imperative for rectifying disfigurement in involute infantile hemangiomas.5 Propranolol and adjunct therapies find application in addressing specific syndromes linked with infantile hemangiomas, thereby broadening therapeutic approaches.7
A Case Report on Infantile Hemangioma
Conclusion
The management landscape of infantile hemangiomashas ............. undergone significant transformation over the past decade, primarily driven by the fortuitous discovery of the efficacy of systemic β-blockers. This discovery has not only expanded therapeutic options but has also sparked interest in the potential use of topical Timolol for superficial lesions. Moreover, a deeper understanding of the indications and limitations of laser therapy has emerged, alongside advancements in bench research elucidating infantile hemangiomas origin and growth patterns. While observation suffices for many infantile hemangiomas, medical or surgical intervention is warranted in others. As intervention modalities and thresholds are expected to evolve, maintaining awareness of these advancements is crucial. In cases where complications are anticipated or intervention thresholds are uncertain, referral to experienced specialists or multidisciplinary vascular anomalies centers can be advantageous. Overall, continued research
efforts hold promise for further elucidating the etiology of infantile hemangiomas, potentially leading to pathogenesisdirected therapeutic options. This evolving landscape underscores the importance of a dynamic and collaborative approach to infantile hemangiomas management, with the ultimate goal of optimizing outcomes and improving the quality of life for affected infants.
Systemic medication goes a long way in resolving large hemangiomas thereby preventing ulceration, bleeding and oozing from them. This was observed in the case presented.
References
1. Holland KE, Drolet BA. Infantile hemangioma. Pediatr Clin North Am. 2010;57(5):1069-1083. doi:10.1016/j.pcl.2010.07.008
2. Takahashi K, Mulliken JB, Kozakewich HP, Rogers RA, Folkman J, Ezekowitz RA. Cellular markers that distinguish the phases of hemangioma during infancy and childhood. J Clin Invest. 1994;93(6):2357-2364. doi:10.1172/JCI117241
3. Mendiratta V, Jabeen M. Infantile hemangioma: An update. Indian J Dermatol Venereol Leprol 2010;76:469-75
4. Abraham A, Job AM, Roga G. Approach to infantile
hemangiomas. Indian J Dermatol 2016;61:181-6
5. Darrow DH, Greene AK, Mancini AJ, Nopper AJ; SECTION ON DERMATOLOGY, SECTION ON OTOLARYNGOLOGY–HEAD AND NECK SURGERY, and SECTION ON PLASTIC SURGERY. Diagnosis and Management of Infantile Hemangioma. Pediatrics. 2015;136(4):e1060-e1104. doi:10.1542/peds.2015-2485
6. Kowalska M, Debek W, Matuszczak E. Infantile Hemangiomas: An Update on Pathogenesis and Treatment. J Clin Med. 2021;10(20):4631. Published 2021 Oct 9. doi:10.3390/jcm10204631
7. Ainipully AM, Narayanan SK, Vazhiyodan AP, Somnath P. Oral Propranolol in Infantile Hemangiomas: Analysis of Factors that Affect the Outcome. J Indian Assoc Pediatr Surg. 2019;24(3):170-175. doi:10.4103/jiaps.JIAPS_12_18
8. Chinnadurai S, Sathe NA, Surawicz T. Laser treatment of infantile hemangioma: A systematic review. Lasers Surg Med. 2016;48(3):221-233. doi:10.1002/lsm.22455
9. Smith CJF, Friedlander SF, Guma M, Kavanaugh A, Chambers CD. Infantile Hemangiomas: An Updated Review on Risk Factors, Pathogenesis, and Treatment. Birth Defects Res. 2017;109(11):809-815. doi:10.1002/bdr2.1023
MUMBAI 202
MUMBAI 2025
1 Day Conference, Hands on Workshop and Exhibition
AESTHETICCON Mumbai 2025 is just the event for you with practical insights shared in the Conference, tips while training in the Hands on workshop and interaction
AESTHETICCON Mumbai 2025 is just the event for you with practical insights shared in the Conference, tips while training in the Hands on workshop and interaction with product manufacturers.
Spend the day catching up and meeting with your fellow Dermatologists colleagues.
