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Fernández Faith E, Shah S, Witman PM, Harfmann K, Bradley F, Blei F, Pope E, Alsumait A, Gupta D, Covelli I, Streicher JL, Cotton C, Tollefson M, Nguyen H, Hunt R, Moore-Clingenpeel M, Frieden IJ. Clinical Features, Prognostic Factors, and Treatment Interventions for Ulceration in Patients With Infantile Hemangioma. JAMA Dermatol 2021; 157:566-572. [PMID: 33787840 DOI: 10.1001/jamadermatol.2021.0469] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Ulceration is a common complication of infantile hemangioma (IH), which leads to substantial morbidity. Ulceration in IH has not been systematically studied since the advent of β-blocker therapy for IH. Objectives To examine treatment interventions used for ulceration in IH and identify clinical prognostic indicators of healing time. Design, Setting, and Participants A retrospective, multicenter cohort study was conducted on 436 consecutive patients with a clinical diagnosis of ulcerated IH and available clinical photographs. Patients receiving care at tertiary referral centers evaluated between 2012 and 2016 were included; statistical and data analysis were performed from February 7 to April 27, 2020. Exposures Clinical characteristics, treatment interventions, course, complications, and resource use were analyzed. Treatment interventions for ulceration in IH included local (wound care, topical), systemic (β-blocker, corticosteroids), and procedural (pulsed-dye laser). Main Outcomes and Measures The primary end point was time to complete or nearly complete ulceration healing. Clinical characteristics were analyzed to determine the responses to most common interventions and prognostic factors for healing of ulceration. Results Of the 436 patients included in the study, 327 were girls (75.0%); median age at ulceration was 13.7 weeks (interquartile range, 8.86-21.30 weeks). The median heal time was 4.79 weeks (95% CI, 3.71-5.86 weeks) with wound care alone, 5.14 weeks (95% CI, 4.57-6.00 weeks) with timolol, 6.36 weeks (95% CI, 5.57-8.00 weeks) with a systemic β-blocker, and 7.71 weeks (95% CI, 6.71-10.14 weeks) with multimodal therapy. After adjusting for IH size, a dose of propranolol less than or equal to 1 mg/kg/d was associated with shorter healing time compared with higher propranolol doses (hazard ratio, 2.04; 95% CI, 1.11 to 3.73; P = .02). Size of the IH was identified as a significant prognostic factor for healing time in multivariable analysis. Increasing size of IH portends a proportionately longer time to heal of the ulceration. Conclusions and Relevance Despite the use of β-blockers, this cohort study found that a subset of patients with IH ulceration continued to experience prolonged IH healing times. Larger IH size appears to be a poor prognostic factor for time to heal. For patients requiring systemic therapy, initiation of propranolol at lower doses (≤1 mg/kg/d) should be considered.
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Affiliation(s)
- Esteban Fernández Faith
- Division of Dermatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | - Sonal Shah
- Department of Dermatology, School of Medicine, University of California, San Francisco.,Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Patricia M Witman
- Division of Dermatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | - Katya Harfmann
- Division of Dermatology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | - Flora Bradley
- Department of Dermatology, School of Medicine, University of California, San Francisco
| | - Francine Blei
- Department of Pediatrics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Elena Pope
- Section of Pediatric Dermatology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Anwar Alsumait
- Section of Pediatric Dermatology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Deepti Gupta
- Department of Dermatology, University of Washington School of Medicine, Seattle
| | - Isabela Covelli
- Department of Dermatology, University of Washington School of Medicine, Seattle
| | - Jenna L Streicher
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Dermatology, Indiana University School of Medicine, Indianapolis
| | - Colleen Cotton
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Division of Pediatric Dermatology, Medical University of South Carolina, Charleston
| | - Megha Tollefson
- Departments of Dermatology and Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Henry Nguyen
- Departments of Dermatology and Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Raegan Hunt
- Departments of Dermatology and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Ilona J Frieden
- Department of Dermatology, School of Medicine, University of California, San Francisco
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You Y, Li Y, Xiao Y, Zhang J. Propranolol vs. steroids in the treatment of infantile hemangiomas: A meta-analysis. Mol Clin Oncol 2021; 15:156. [PMID: 34178327 PMCID: PMC8220686 DOI: 10.3892/mco.2021.2318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 03/03/2021] [Indexed: 12/02/2022] Open
Abstract
Infantile hemangioma (IH) is a common disease, and drug therapy is the most common treatment method. Clinically, steroids have long been used as first-line drugs, but in recent years, some doctors have begun to use propranolol to treat infantile hemangiomas (IHs). The present study performed a meta-analysis to evaluate the clinical effects of propranolol in comparison with steroids in the treatment of infantile hemangiomas. A detailed review of the literature on PubMed, Cochrane Library, Embase and Web of Science was performed prior to March 31, 2020. All literatures were compared with the clinical effects of propranolol and steroids in the treatment of infantile hemangiomas. A total of two researchers independently screened the literature according to the selection criteria, extracted data and assessed the risk of bias for the included studies. Review Manager 5.3 was used to meta-analyze all the included studies. According to the selection criteria, nine articles were included in the present study. The meta-analysis revealed that the effective rate of propranolol was greater than that of steroids in treating infantile hemangiomas [odds ratio (OR), 3.96, 95% confidence interval (CI), 2.47-6.37; P<0.00001]. Additionally, propranolol had fewer complications than steroids (OR, 0.21; 95% CI, 0.12-0.36; P<0.00001). The recurrence rate of the two groups was not statistically different (OR, 1.83; 95% CI, 0.59-5.70; P=0.3) and the surgical resection rate of propranolol was lower than steroids (OR, 0.19; 95% CI, 0.08-0.46; P=0.0002). The present study demonstrated that propranolol is more effective than steroids for the treatment of IHs, and provides a theoretical basis for the clinical use of propranolol as an alternative to steroids.
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Affiliation(s)
- Yiting You
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Yadong Li
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Yiting Xiao
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Jinsong Zhang
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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3
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Ji Y, Yang K, Zhou J, Zhang X, Xiang B, Jiang X, Xu X, Qiu T, Dai S, Kong F, Lu G, Qiu Q, Zhang Y, Chen S. Propranolol for the treatment of ulcerated infantile hemangiomas: A prospective study. J Am Acad Dermatol 2021; 86:1149-1151. [PMID: 33895205 DOI: 10.1016/j.jaad.2021.04.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China.
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xuepeng Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xian Jiang
- Department of Dermatology, West China Hospital of Sichuan University, Chengdu, China
| | - Xuewen Xu
- Department of Burn and Plastic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Shiyi Dai
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Feiteng Kong
- Department of Pediatric Surgery, Sichuan Women and Children's Hospital, Chengdu, China
| | - Guoyan Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University Chengdu, Chengdu, China
| | - Qingxia Qiu
- Department of Pediatric Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China
| | - Yongbo Zhang
- Department of Pediatric Surgery, Chengdu Women and Children's Central Hospital, Chengdu, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China.
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Leung AKC, Lam JM, Leong KF, Hon KL. Infantile Hemangioma: An Updated Review. Curr Pediatr Rev 2021; 17:55-69. [PMID: 32384034 DOI: 10.2174/1573396316666200508100038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/20/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infantile hemangiomas are the most common vascular tumors of infancy, affecting up to 12% of infants by the first year of life. OBJECTIVE To familiarize physicians with the natural history, clinical manifestations, diagnosis, and management of infantile hemangiomas. METHODS A Pubmed search was conducted in November 2019 in Clinical Queries using the key term "infantile hemangioma". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article. RESULTS The majority of infantile hemangiomas are not present at birth. They often appear in the first few weeks of life as areas of pallor, followed by telangiectatic or faint red patches. Then, they grow rapidly in the first 3 to 6 months of life. Superficial lesions are bright red, protuberant, bosselated, or with a smooth surface, and sharply demarcated. Deep lesions are bluish and dome-shaped. Infantile hemangiomas continue to grow until 9 to 12 months of age, at which time the growth rate slows down to parallel the growth of the child. Involution typically begins by the time the child is a year old. Approximately 50% of infantile hemangiomas will show complete involution by the time a child reaches age 5; 70% will have disappeared by age 7; and 95% will have regressed by 10 to 12 years of age. The majority of infantile hemangiomas require no treatment. Treatment options include oral propranolol, topical timolol, and oral corticosteroids. Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration in areas where serious complications might ensue, interference with vital structures, life- or function-threatening complications, and significant disfigurement. CONCLUSION Treatment should be individualized, depending upon the size, rate of growth, morphology, number, and location of the lesion (s), existing or potential complications, benefits and adverse events associated with the treatment, age of the patient, level of parental concern, and the physician's comfort level with the various treatment options. Currently, oral propranolol is the treatment of choice for high-risk and complicated infantile hemangiomas. Topical timolol may be considered for superficial infantile hemangiomas that need to be treated and for complicated infantile hemangiomas in patients at risk for severe adverse events from oral administration of propranolol.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, and Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
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Igarashi A, Hata I, Yuasa M, Okuno T, Ohshima Y. A case of an infant with extremely low birth weight and hypothyroidism associated with massive cutaneous infantile hemangioma. J Pediatr Endocrinol Metab 2018; 31:1377-1380. [PMID: 30367808 DOI: 10.1515/jpem-2018-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/02/2018] [Indexed: 01/21/2023]
Abstract
Background Although hepatic infantile hemangioma (IH) may correlate with consumptive hypothyroidism consequent to the overexpression of thyroid hormone inactivating enzyme by hemangioma cells, hypothyroidism has been rarely recognized in infants with cutaneous hemangioma. Case presentation A male infant born at 28 weeks of gestational age with an extremely low birth weight (775 g) developed a massive cutaneous hemangioma on his neck and severe abdominal distension. Imaging examinations detected a small mass lesion in the brain but no hepatic hemangioma. Laboratory findings at the age of 26 days revealed hypothyroidism. Although high-dose levothyroxine therapy failed to normalize the thyroid function, hypothyroidism improved and cutaneous hemangioma regressed after initiating propranolol therapy. Conclusions Our findings suggest that consumptive hypothyroidism should be considered as a critical comorbidity in patients with massive cutaneous IH. Propranolol therapy can effectively normalize thyroid function and cause hemangioma regression.
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Affiliation(s)
- Aiko Igarashi
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Ikue Hata
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Miori Yuasa
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Takashi Okuno
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Yusei Ohshima
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
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Calatayud-Pascual MA, Sebastian-Morelló M, Balaguer-Fernández C, Delgado-Charro MB, López-Castellano A, Merino V. Influence of Chemical Enhancers and Iontophoresis on the In Vitro Transdermal Permeation of Propranolol: Evaluation by Dermatopharmacokinetics. Pharmaceutics 2018; 10:pharmaceutics10040265. [PMID: 30544534 PMCID: PMC6321337 DOI: 10.3390/pharmaceutics10040265] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/18/2018] [Accepted: 12/05/2018] [Indexed: 12/19/2022] Open
Abstract
The aims of this study were to assess, in vitro, the possibility of administering propranolol transdermally and to evaluate the usefulness of the dermatopharmacokinetic (DPK) method in assessing the transport of drugs through stratum corneum, using propranolol as a model compound. Four chemical enhancers (decenoic and oleic acid, laurocapram, and R-(+)-limonene) and iontophoresis at two current densities, 0.25 and 0.5 mA/cm2 were tested. R-(+)-limonene, and iontophoresis at 0.5 mA/cm2 were proven to be the most efficient in increasing propranolol transdermal flux, both doubled the original propranolol transdermal flux. Iontophoresis was demonstrated to be superior than the chemical enhancer because it allowed faster delivery of the drug. The DPK method was sufficiently sensitive to detect subtle vehicle-induced effects on the skin permeation of propranolol. The shorter duration of these experiments and their ability to provide mechanistic information about partition between vehicle and skin and diffusivity through skin place them as practical and potentially insightful approach to quantify and, ultimately, optimize topical bioavailability.
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Affiliation(s)
- María Aracely Calatayud-Pascual
- Instituto de Ciencias Biomédicas, Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Alfara del Patriarca, Spain.
| | - María Sebastian-Morelló
- Instituto de Ciencias Biomédicas, Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Alfara del Patriarca, Spain.
| | - Cristina Balaguer-Fernández
- Instituto de Ciencias Biomédicas, Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Alfara del Patriarca, Spain.
| | - M Begoña Delgado-Charro
- Department of Pharmacy & Pharmacology, University of Bath, Claverton Down, Bath BA2 7AY, UK.
| | - Alicia López-Castellano
- Instituto de Ciencias Biomédicas, Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Alfara del Patriarca, Spain.
| | - Virginia Merino
- Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València, 46100 Burjassot, Spain.
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Universidad de València, Avda. Vicente Andrés Estellés sn, 46100 Burjassot, Spain.
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