血管瘤治疗中应注意的几个问题

血管瘤消退并不代表消失

血管瘤可以简单分为消退型和不消退型2类。3岁时30%消退，5岁时50%消退，7岁时70%消退，9岁时90%消退，但这些数据仅是估计。当然，文献报道的消退率各不相同，血管瘤消退的可能性多是猜测。多发性血管瘤，每个病变的消退速度不一。更重要的是，血管瘤能否消退，消退后会不会引起美观问题，尚不能预测。多数报道表明，近50%的血管瘤会造成永久畸形。家长应当明白，消退并不意味着完全消失（Involute does not mean disappearance）。

激光不是魔术（Lasers are not magic）

 血管瘤患儿家长总是希望将病变立即清除，对激光治疗寄予厚望。须知，脉冲染料激光的平均穿透深度为1.2mm，但常被用来治疗10倍于其厚度的血管瘤。潜行分离的皮肤如用激光治疗，通常导致边缘坏死。应当鼓励家长，将激光治疗作为残留的毛细血管扩张的最终治疗手段，特别是鼻、唇病变。脉冲染料激光（PDL）是治疗血管性病灶的标准激光，主要用于表浅血管瘤的早期干预、溃疡病灶的处理和消退期遗留毛细血管扩张的治疗。带有皮肤冷却系统的595nm长脉冲染料激光的疗效优于传统585 nmPDL。低能量PDL照射血管瘤表面溃疡，可加速创面愈合。PDL和长PDL对毛细血管扩张安全有效。激光治疗不能作为血管瘤的常规治疗手段，因为对表浅型血管瘤，外用β受体阻滞剂如噻吗洛尔溶液或凝胶也有很好的疗效和安全性。

普遍认为，激光对前驱期的血管瘤作用不大：激光治疗不能停止血管瘤生长，并可造成溃疡。激光的凝固作用也不能阻滞肿瘤的进展，因为577～585 nm脉冲染料激光对皮肤的穿透深度仅为0.75～1.2 mm。另外，激光处理过的皮肤，发生萎缩和色素脱失的几率是未予处理而消退者的3倍。

Parents, especially first-time mothers, will virtually always want to get rid of the lesions immediately. Many parents present to the surgeon after either consulting with another practitioner or reading an article on the Internet, which touts lasers as some sort of panacea. And remarkably, insurance companies are willing to pay large amount of money for the lasers when the patient actually needs an excision. Pulsed-dye lasers that penetrate an average of 1.2-mm depth are often used to treat hemangiomas that are 10 times thicker than the depth of penetration. For example, a pulsed-dye laser will only scar the surface of a Cyrano nose; however, if it is first treated by laser, the nose tends to loose skin after undermining. Undermining skin that has been treated by laser will usually lead to some edge necrosis. The parents should be encouraged to reserve laser treatment as the final modality for any remaining telangiectasias, especially on the lip and nose. 

Laser photocoagulation is not specifically focused on hemangioma’s proliferating cells. Moreover, even in the experienced hands, pulsed dyer laser can sometimes cause ulceration and subsequent depigmentation and scarring. The same caveat applies to the use of intralesional (bare fiber) laser therapy.

There is a general agreement that there is no part for laser in the prodromal phase of hemangiomas: phototherapy will not stop growth and may cause ulceration. Nor will prompt photocoagulation halt progression of the tumor because the pulsed dye laser penetrates only 0.75-1.2 mm (577-585 nm) into the dermis. Furthermore, laser-treated skin was 3 times more likely to evidence atrophy and hypopigmentation than the skin of untreated, involuted tumors. 

强调药物治疗

家长应当明白，口服类固醇激素是经时间考验的血管瘤治疗方法之一。但短期应用普萘洛尔（3～9个月）十分有效，已经取代激素作为一线治疗。小于3个月的患儿，服药前先咨询心脏科医师，测量基线数据，包括拍照、超声检查、血常规、EKG等。住院1天，观察服药后有无心动过缓、低血压、低血糖，按2～3mg/kg•d、分2～3次服药，连服3～9个月。3～4周内逐渐停药。对眶周血管瘤，可局涂1%普萘洛尔乳霜，或0.5%噻吗洛尔。对普萘洛尔无效（抵抗）的患者，可考虑皮下注射α干扰素或静脉推注长春新碱。Parents should be made aware that systemic steroid treatment is one of the few therapies for hemangiomas that have been time-tested. More recently, propranolol for short-term use (3–9 months) has been highly effective and has replaced steroids as first-line treatment. In infants younger than 3 months, starting the medication requires hospital admission to watch for bradycardia, hypotension, and hypoglycemia, though just for 1 day. Preoperatively, photographs, ultrasound, routine blood work, and a cardiology visit (for echo and EKG) are required. The drug works well if started at 2 to 3 mg/kg/d, divided into 2 or 3 doses, and can be used for 3 to 9 months. Gradual discontinuation can take 3 to 4 weeks. Results can be grippingly rapid, and the literature certainly supports its use.  Topical propranalol as a 1% cream or timolol 0.5% can be tried for some lesions around the eye to jump-start involution.

手术和激光治疗时机

除个别情况外（危及生命或影响重要功能），手术应在1岁后实施（The child should not be operated before the age of 1 year except in certain cases）。一般主张在学龄前实施，主要用于切除消退期或治疗后残存的病变，如瘢痕、皮肤凹陷、臃余皮肤、纤维脂肪残留物等，减轻患儿及家长因美观和功能问题而造成的心理负担。因血管瘤的消退完成期多在9岁以后，所以整形手术的最佳时机为8～12岁。至于激光，虽然某些学者有不同意见，推荐在15个月后采用，治疗计划宜在3.5岁完成。此时儿童的身体形象开始发育，且有可能遭到其他儿童的嘲笑。

参考文献

Zide BM, Levine SM. Hemangioma update: pearls from 30 years of treatment. Ann Plast Surg, 2012,69(1):99-103.Greene AK1, Rogers GF, Mulliken JB. Management of parotid hemangioma in 100 children. Plast Reconstr Surg, 2004,113(1):53-60.