We read the article by Smit and Meyer with keen interest. We wish to express the following comments:
Intralesional bleomycin injection (IBI) is a newer form of therapy for capillary hemangioma with encouraging results. IBI was used for the first time for complicated cutaneous hemangiomas. Experience with IBI for periocular capillary hemangiomas is very limited.
Authors diagnosed capillary hemangioma by clinical examination only. We believe clinical evaluation should have been combined with ultrasonography or magnetic resonance imaging or color doppler to differentiate hemangioma from vascular malformation. Color doppler is also of immense utility during follow-up in detecting size, color, and blood flow changes after IBIs. Blood flow in capillary hemangioma declines after four to five IBIs; blood flow signal disappears earlier than color (usually after five to six IBIs for a lesion diameter less than 4 cm).
Authors discontinued therapy after administering nine IBIs in case one and after five IBIs in case two. We appreciate the result with respect to opening of eye and increase in vertical height of palpebral fissure which might be adequate to prevent stimulus deprivation amblyopia, however, post IBI Figures 2 and 4 clearly depict significant residual capillary hemangioma covering the forehead, nose, upper lip, and even left upper eyelid of case 1 and forehead, nose and right upper eyelid of case 2 respectively. We believe the treatment should not have been stopped at this stage. The hemangioma involving forehead, nose, and lips still required intralesional bleomycin. It has been suggested that the interval of injection should be 3-4 weeks with total times lesser than 7 times during one therapeutic period. Another therapeutic period may be started 3 months later if further treatment was necessary. The total quantity of bleomycin for a child should be less than 40 mg in one treatment periods. Luo and Jhao reported very large series of 82 cases of infantile hemangiomas which involuted completely after treatment with the sclerosing mixture composed of 2% lidocaine, 5 mg dexamethasone and 8 mg bleomycin A5 and also used oral prednisolone (2-5 mg/kg every other day). Combination of dexamethasone with bleomycin as well as oral prednisolone has been advocated to treat effectively the patients at proliferating stage observed in the 3rd and 6th month in many cases of infantile hemangioma and also to circumvent the dose restriction of bleomycin i.e., the drug quantity given in one time may be deficient for big hemangioma(>4 cm).
Authors suggest use of bleomycin in the treatment of eyelid hemangiomas where conventional modalities have been unsuccessful or where treatment with beta-blockers may be contraindicated. Many investigators recommend oral propranolol as the first line of therapy for infantile hemangioma. Readers would be interested to know why authors did not treat these cases with oral propranolol as first line therapy.
1. Smit DP, Meyer D. Intralesional bleomycin for the treatment of periocular capillary hemangiomas Indian J Ophthalmol. 2012;60:326–8
2. Sarihan H, Mocan H, Yildiz K, Abes M, Akyazici R. A new treatment with bleomycin for complicated cutaneous hemangioma in children Eur J Pediatr Surg. 1997;7:158–62
3. Luo QF, Zhao FY. The effects of Bleomycin A5 on infantile maxillofacial haemangioma Head Face Med. 2011;7:11
4. Luo Q, Zhao F. How to use bleomycin A5 for infantile maxillofacial haemangiomas: Clinical evaluation of 82 consecutive cases J Craniomaxillofac Surg. 2011;39:482–6
5. Yang Y, Sun M, Cheng X, Hu X, Zhang P, Ma Q, et al Bleomycin A5 plus dexamethasone for control of growth in infantile parotid hemangiomas Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:62–9
6. Holmes WJ, Mishra A, Gorst C, Liew SH. Propranolol as first-line treatment for rapidly proliferating infantile haemangiomas J Plast Reconstr Aesthet Surg. 2011;64:445–51