Adrenal Suppression following Steroid Treatment of Infantile Hemangiomas

Abstract

Sir:FigureInfantile hemangiomas are the most common childhood tumors. A rapidly proliferating hemangioma can have a devastating functional and cosmetic effect. Systemic or intralesional steroid administration has been the criterion standard treatment to halt such proliferation. Although prolonged treatment with high-dose steroids is sometimes necessary, routine testing of possible adrenal suppression is rarely performed,1–3 especially following intralesional administration. We report on a prospective study investigating the prevalence of adrenal suppression after the use of systemic or intralesional steroids. Seven consecutive patients who were treated with intralesional or systemic steroids were tested with the short Synacthen test 6 weeks after completion of treatment. Those treated with systemic steroids had a reducing dose of the medication over several weeks before complete discontinuation of their treatment. We found that five of seven patients (71 percent) had adrenal suppression after their steroid treatment, requiring hydrocortisone replacement. All of these patients were clinically asymptomatic (Table 1). Interestingly, patients treated with intralesional steroid injections were as likely to suffer from adrenal suppression as those treated with high-dose systemic steroids.Table 1: ResultsOur study highlighted the high prevalence of adrenal suppression following systemic or intralesional steroid treatment for hemangioma. Replacement hydrocortisone is important in such patients, as they may face adrenal crisis if they undergo elective surgery or suffer an infection. Since the first report of the extremely impressive efficacy of propranolol in treating a rapidly proliferating hemangioma was published by Léauté-Labrèze et al. in December of 2008,4 many leading units worldwide have been using propranolol in patients with complicated hemangiomas. As the safety profile and ideal treatment regimen of propranolol are currently being investigated, and while steroids are still used in some patients, we suggest that routine Synacthen test should be carried out after the use of systemic or intralesional steroids. At a time when propranolol treatment is found to be highly effective and relatively safe, its use as a first-line treatment may need to be considered for all rapidly proliferating infantile hemangiomas. Joannis Constantinides, M.R.C.S.(Ed.) Phoebe Prowse, M.R.C.S. Whiston Hospital Cath Gorst, R.S.C.N./R.G.N. Mohammed Ali Didi, M.R.C.P. Se Hwang Liew, F.R.C.S.(Plast.) Alder Hey Children's Hospital, Liverpool, United Kingdom