Using Topical Citric Acid to Treat an Infected Ulcerated Hemangioma in an Infant: A Case Study

Infantile hemangiomas (IHs) are the most common benign vascular tumors in children younger than 12 months of age; incidence varies from 10% to 12%.^1,2 After initial proliferation, most IHs involute spontaneously and do not need intervention unless a complication occurs. Ulceration is the most common complication, with frequency between 10% and 30%.^3,4 Ulceration occurs around the fourth month of life, generally seen in tense, rapidly proliferating hemangiomas; though an ulcer may develop at any site, it occurs more commonly in the anogenital, lip, and chest regions. Despite evidence-based wound care, ulcerated IHs have been shown to be difficult to heal. These ulcers cause pain, bleeding (41%), and infection (16%); interfere with sleep and breast-feeding; and may result in disfigurement and scarring.^5,6 Oral propranolol (beta-blocker) therapy has been shown to be beneficial but is associated with 31% of adverse effects that include bradycardia, hypotension, hypoglycemia, gastrointestinal discomfort, and bronchospasm.⁷ In addition, healing may require 1.5 to 6 months of treatment.^8,9 Alternatively, topical application of 0.5% timolol gel has been reported to be an appropriate treatment approach for ulcerated hemangiomas but only in ulcers less than approximately 3 cm in size; healing may take 2 to 3 months.¹⁰

Citric acid has been reported to be effective against bacterial pathogens, including multiple antibiotic-resistant strains and Pseudomonas aeruginosa.^11,12 Citric acid creates an acidic environment in the wound milieu, making conditions unsuitable for bacteria to grow and multiply.¹³ Citric acid has been used in the treatment of pediatric patients with a variety of wounds, such as injection abscess, burn infections, and multiple abscess refractory to conventional treatment modality without any adverse effects.^14-17

Previous successful uses of citric acid in the treatment of injection abscess in a child less than 1 year old, multiple abscesses in a 3-year-old child,¹³ and burn infections in children of 3 to 4 years¹⁷ guided the authors’ decision to use a citric acid ointment to treat a large (> 3 cm) ulcerated hemangioma infected with P aeruginosa that had not responded to conventional therapy (antibiotics and local wound care) for more than 2 months in an infant.

A 6-month-old otherwise healthy infant presented with an ulcerative lesion on the left groin with purulent discharge of 2 months’ duration located over a hemangioma that was diagnosed soon after birth. A dermatologist prescribed cephalexin (125 mg) daily in 2 divided doses, 5 drops of hydroxyzine hydrochloride once daily, and mupirocin ointment 3 times daily, all for 7 days. Despite this treatment, the pustular growth developed into an infected ulcer. The patient was taken to a plastic and cosmetic surgery center, where the following were prescribed: syrup amoxycillin (200 mg) plus clavulanic acid (28.5 mg) daily in 2 divided doses, liquid paracetamol 1 mL twice daily, and local care of the ulcer comprising irrigation and washing of the ulcer with normal saline and dressing with betadine on alternate days for 11 days. This treatment yielded no healing response; no change in the ulcer was noted.

When the patient was brought to the treating hospital, the infected ulcer measured 7 cm x 5 cm with purulent discharge (Figure 1). Culture and antimicrobial susceptibility testing of the purulent discharge yielded P aeruginosa susceptible to amikacin, gentamicin, netilmicin, and ciprofloxacin, and resistant to the rest of the tested antimicrobial agents, including amoxicillin plus clavulanic acid. Based on earlier experiences in which 3% citric acid ointment was found effective in the management of a variety of wounds, such as injection abscesses, multiple abscesses, and burn infections in children, the authors considered its use in this patient. Citric acid ointment was prepared by triturating 3 g of a fine ground powder of citric acid into 30 g of 2% lignocaine, using 70 g of petroleum jelly as a base. This ointment was applied once daily after the ulcer was irrigated with normal saline, with no notable adverse local effects with the exception of mild pain during dressing.

After 7 applications, ulcer size substantially reduced to 1.5 cm x 1 cm (Figure 2). The depth of the ulcer, amount of exudate, and periwound induration had decreased. As dressing changes continued over the course of treatment, the infant became used to the dressing changes and was no longer upset/uncomfortable during the dressings. The ulcer healed completely with minimal scarring after 24 applications (Figure 3). No antibiotics were administered during the course of treatment. The patient was followed-up monthly for 15 months. The ulcer did not recur, and the patient showed complete resolution of the hemangioma as well (Figure 4).

Although IHs are the most common benign vascular tumors in children, characteristically proliferating during the first year of life, usually they spontaneously involute, making intervention necessary only in complicated cases. Ulceration of the IH is one of the most common complications and is difficult to manage because of poor healing response.^3,4 Oral propranolol therapy, although reported to be beneficial, is known to be associated with many side effects, such as bradycardia, hypotension, hypoglycemia, gastrointestinal discomfort, and bronchospasm,⁷ and requires long-term therapy (1.5–6 months).^8,9 Topical application of timolol has been reported to be effective in smaller ulcers (< 3 cm), but it requires 2 to 3 months for complete healing and for the ulcer and hemangioma to resolve.¹⁰ Studies have shown a variety of nonhealing ulcers, skin and soft tissue infections (eg, injection abscesses, tuberculous lymphadenitis with multiple discharging sinuses, leprosy ulcers, burn infections, etc) were healed successfully by using topical application of 3% citric acid ointment, including ulcers in pediatric patients.^14-17 Topical application of 3% citric acid ointment also has been found to be effective in the treatment of diabetic foot ulcers, oral ulcers, and a variety of other wounds nonresponsive to conventional antibiotic therapy and local wound care.^18-21 Except for mild to moderate skin irritation, no major adverse events were noted. In the present case, citric acid ointment was prepared using petroleum jelly and 2% lignocaine as a base to treat an ulcerated hemangioma infected with P aeruginosa that was unresponsive to conventional therapy (antibiotics and local wound care). Lignocaine was added to citric acid ointment to minimize the irritation to the skin, which is common in superficial ulcers.^12,17 Topical application of citric acid to the ulcerated hemangioma resulted in complete healing of the ulcer in 24 applications over 24 days, followed by complete resolution of hemangioma at a subsequent visit on day 25 and thereafter at weekly follow-up. No adverse events or any kind of pain was noted at follow-up visits. No ulcer recurrence was noted at the 15-month follow-up.

Although many topical agents such as silver sulfadiazine compounds, povidone-iodine, hydrogen peroxide, Dakin’s solution, chloroxynelol, polyhexamethylene biguanide, mafenide acetate, and chlorhexidine may have been found to be effective in terms of antimicrobial activity, they can be toxic to cells involved in the wound healing process.²² Comparatively, 3% citric acid ointment used as a topical agent has been shown to have the best outcomes regarding safety and efficacy.¹³

Because this was a single case study, further research, including randomized controlled trials, is warranted to substantiate these findings and to support broader conclusions regarding the use of topical citric acid in the treatment of ulcerated hemangiomas.

An IH and infected ulcer in a 6-month-old patient were resolved without major adverse events using an ointment containing 3% citric acid. This case study, along with previous anecdotal experience, support the use of topical citric acid in similar cases. Further research is recommended

Authors: Basavraj Nagoba, PhD; Milind Davane, MD; Basavraj Warad, MS; Nawab Jamadar, MD; and Ajay M. Gavkare, MD

Affiliation: Maharashtra Institute of Medical Sciences and Research (MIMSR) Medical College Latur, India

Correspondence: Basavraj Nagoba, PhD, Assistant Dean, Research & Development, MIMSR Medical College, Ambajogai Rd, Latur MS 413512, India; dr_bsnagoba@yahoo.com 

Disclosure: The authors disclose no financial or other conflicts of interest.