Maggie McKay (Host): Birthmarks come in a wide variety, but if your child has one, is there reason for concern? And what if it's a vascular birthmark? What is that? We'll talk about vascular birthmarks, what they are, and how they're treated with Dr. Teresa Wright, Chief of Pediatric Dermatology at Le Bonheur Children's Hospital.

 This is the PedsPod by Le Bonheur Children's Hospital.

I'm your host, Maggie MacKay. Welcome Dr. Wright. Thank you so much for making the time to be here.

Teresa Wright, MD, FAAD, FAAP: Hello. Thank you for having me today.

Host: So just to start off with, what is a birthmark?

Teresa Wright, MD, FAAD, FAAP: Well, I think when I say birthmark to families, they always think of things that are definitely present or fully developed at birth, but there are so many different kinds of birthmarks, and while some of them are present and fully apparent or fully formed at birth or very close to the time of birth, there may be others that take a little bit of time to appear and fully develop.

So sometimes when we refer to something as a birthmark, it really means more that the potential for it is present from birth, and it may be that you don't see it in its fully developed form right away, right at the moment of delivery or even in the first few days.

Host: Birthmarks come in a lot of different forms, but what does it mean to have a vascular birthmark, and why do kids get those?

Teresa Wright, MD, FAAD, FAAP: Vascular birthmarks in general are going to be birthmarks that are composed of some kind of blood vessel or blood vessel tissue. And I would say for the most part, for many of them, we really don't understand why some children have them.

Host: Are vascular birthmarks ever a reason for concern? When should somebody see a pediatrician or a dermatologist?

Teresa Wright, MD, FAAD, FAAP: Yes, they can be a cause for concern. So on the very kind of minor, most benign ends, many babies with fair skin may be born with pink to red spots or patches on the middle of the forehead or on the upper eyelids or sometimes on the nape of the neck or the back of the scalp. You may have heard those referred to as angel kisses when they're on the face, or stork bites when they're on the back of the neck. Those are marks that are generally harmless. We often call those nevus simplex, which is more of the medical term for those. And there are areas where there's an increased number of small blood vessels or capillaries in the skin. They usually tend to fade away over time, particularly on the face, and the ones on the back of the head, they're somewhat less likely to disappear completely, but they usually become covered by hair, so they're less of a concern.

And then we have other vascular tumors and vascular malformations, which may cause medical problems. They may cause more extensive cosmetic issues. The most common type of vascular tumor would be an infantile hemangioma. That's a benign blood vessel tumor that usually appears within the first month of life. Depending on how large they are and where they are, they can sometimes impair vital functions. You know, as you can imagine, if they're in or near, you know, the eyelid or somewhere on the face, they may cause a problem with vision or some other vital function. And they can also, you know, be a real cosmetic issue. There's actually a whole list of complications that they may cause.

And then there's a whole category of vascular malformations, which are present and usually more fully formed at birth, where you may have any combination of abnormal capillaries, veins, arteries, and or lymphatics. And, again, depending on the location and the extent, that's really what's going to determine whether those are going to be a problem or not, and when they may be a problem.

Host: When should a parent take their child to a pediatrician or should they go to a dermatologist?

Teresa Wright, MD, FAAD, FAAP: So most things like in the beginning when babies are born, right, they get a good physical exam by a pediatrician soon after they're born and they're usually seeing a pediatrician pretty often in the first few weeks or months of life for just routine checks and immunizations. So I think in general, you know, most pediatricians are going to have a good sense of if there's some kind of birthmark that should be referred to a specialist like the pediatric dermatologist. However, having said that, if the parent is noticing something and they're feeling really anxious or uneasy about it, or they feel like they want an additional opinion or want a specialist to look at it, you know, whether it's just to provide more reassurance, more education, they can always ask their pediatrician for that.

And we are certainly always happy to see you know, patients weren't necessarily going to have a complication, but the parents would like, you know, us to weigh in on what's going on and give them more information.

Host: Right. When is a vascular birthmark considered a vascular anomaly?

Teresa Wright, MD, FAAD, FAAP: Well, I think that's the same thing. I mean, that really just means a vascular abnormality where somewhere along the way during development of an infant, something has kind of gone awry a bit, and you're ending up with an abnormality that's either growth of a vascular tumor or development of a vascular malformation.

So, that's really just, you know, different terms for the same thing, really.

Host: Can you tell us about the Vascular Anomalies Program at Le Bonheur? What kinds of concerns do you see with kids in that program?

Teresa Wright, MD, FAAD, FAAP: So the Vascular Anomalies Clinic here is a multidisciplinary clinic. And I think that's the important thing, because if you don't have a multidisciplinary clinic, you know, a lot of times kids with these different kinds of vascular birth marks or lesions, they end up being sent to specialists of all different kinds, right?

So sometimes there might be a baby with a hemangioma in the eyelid and they might get sent to ophthalmology first, if someone's worried about their vision or if it's, say it's on the face or it's near the nose, they might get sent to the ear, nose and throat doctor first. Or let's say it's just a lump in the skin and people aren't sure what it is, they might refer them to a surgeon first. So historically, these patients get referred kind of into the medical system from into all different avenues and it can be really hard you know, for parents to kind of get consistent information. And then sometimes like the more complicated ones may require the input of multiple specialists. And the nice thing about the multidisciplinary clinic is, you know, we have a group of experienced people from a variety of different disciplines and we all come together, you know, to look at each case.

We have the big clinic once a month usually on the third Tuesday of the month, first thing in the morning, we have a conference where our nurse coordinator puts together a presentation of all the patients who are coming that day. We get to see a little bit of their history. We get to see clinical photographs of what they look like, you know, what their skin problem, their birthmark, their vascular lesion looks like, if they've had any imaging like ultrasounds or an MRI or a CAT scan or whatever. Sometimes those things were done outside. Sometimes they're done here. She'll gather all of that. So we have radiologists present who can review that with us. We have me from dermatology. We've got interventional neurology, interventional radiology, hematology, oncology. We have people from Ear, Nose and Throat and ophthalmology that work with us. So we have, you know, this group of people all come together and then we all go to clinic and the patients are scheduled throughout the day and whatever specialist we've decided they need to see you know, whether it's one of us or it's three or four of us like we all see them that day. So they end up not having to come back from multiple visits to different clinics to see different doctors and we're all there in the same place and we can all talk about what's going on with the patient at the same time.

So I think it just really helps the communication, you know, it helps our level of understanding of what is going on with the patient and what we have to offer the patient. And I think it's really a great way to get the best care to the patients and the best information and support to their families.

Host: That's amazing. It really sounds like Le Bonheur Children's Hospital has it covered, all the bases covered when it comes to vascular anomalies in their program. Um, speaking of, what are the treatments available for vascular anomalies?

Teresa Wright, MD, FAAD, FAAP: So there are quite a few different treatment modalities now, and it really depends on what the lesion is and what kind of symptoms the patient is experiencing. So, many times we see patients who really don't need any treatment. You know, again, parents may just need some information or education about what is going on and what to expect.

I may see hemangiomas, infantile hemangiomas in clinic or a rare or some type of congenital hemangioma, that when I see them, I say, you know what, this is not causing any kind of functional disturbance or threat. This is not causing a significant cosmetic issue or deformity. It should actually, over time, go away quite well.

So I don't think that we need to intervene at all. The ones that do need intervention, I typically treat them medically. We have an oral medication that we can give that works quite well. Rarely, we might need to offer a surgical intervention for different vascular malformations. You know, sometimes if it's just a matter of like bigger veins, almost like, um, if you think of like varicose veins, sometimes to control that or prevent development of varicose veins where there's an abnormal collection of veins, like in a leg, we might recommend a compression garment, which is, you know, like a special stocking that applies a little pressure. That can be helpful. Sometimes we can offer sclerotherapy, which is a treatment done by interventional radiology where a variety of different medicines and solutions can be injected into abnormal blood vessels to help them kind of shrink down, kind of shrink and scar down, which can help improve the appearance or symptoms from those.

Sometimes a surgical intervention might be appropriate. In the last years, there's really been kind of an explosion of research into a lot of these, and an increased knowledge of pathways, that are abnormal and some newer medicines that can help some of these other conditions with, you know, a variety of different venous malformations. And so we're starting to use some of those oral medications as well.

Host: That's great. I bet that takes a lot of stress out of it for parents. Like you said, they don't have to run around from this doctor to that doctor. You guys figure it out first and then tell them what they need. How do you know whether to treat a vascular anomaly or just monitor it as a child grows?

Teresa Wright, MD, FAAD, FAAP: Yeah, that's a great question. I think most of the time it comes down to symptoms, right. Is it bothering them? But also, what is it and what is it likely to do down the road? We are in general going to be less aggressive about intervention for something that we feel is not really bothering the child in terms of causing symptoms like pain or swelling or limiting their ability to do their normal daily activities, participate in whatever things they want to participate in; as long as we know that it's not something that is likely going to progress and cause problems down the road if we don't intervene. So I think that's really the key is really having a good understanding of what it is, you know, being as certain as possible about the diagnosis and that enabling us to have a good idea of what's the natural history.

Like, what is this likely to do? But for the most part, we don't like to do, you know, a surgery or something more aggressive, particularly if whatever it is is not causing any problems because obviously all surgeries and you know, more invasive interventions carry some risks and medicines carry some possible side effects, you know. So I think we're really mindful about only treating the ones that are in fact causing a problem or are highly likely to cause a problem if we don't do something now.

Host: Absolutely. Thank you so much for joining us today. We appreciate you sharing your expertise with us and, letting us know all the differences between birthmarks and vascular anomalies and all the things that parents need to know. Thank you.

Teresa Wright, MD, FAAD, FAAP: Thank you for having me.

Host: Again, that's Dr. Teresa Wright. Visit Le Bonheur.org to learn more about the multidisciplinary Vascular Anomalies Program at Le Bonheur Children's Hospital. If you found this podcast helpful, please share it on your social channels and check out our entire library for topics of interest to you. This is the Peds Pod by Le Bonheur Children's Hospital. Thank you for listening.