1
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Sharma A, Gupta M, Mahajan R. Infantile hemangiomas: a dermatologist's perspective. Eur J Pediatr 2024; 183:4159-4168. [PMID: 39052139 DOI: 10.1007/s00431-024-05655-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/31/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024]
Abstract
Infantile hemangioma (IH), the most common vascular tumor in pediatrics, is thought to arise from aberrant stem cell responses to stimuli such as hypoxia. This review explores the diverse manifestations, complications, and management strategies for IH, emphasizing the importance of a multidisciplinary approach. The epidemiology and risk factors associated with IH, including connections to prematurity, low birth weight, and family background, are discussed. The intricate pathogenesis involving hemangioma stem cells, KIAA1429, hypoxia, and the renin-angiotensin system is examined. The natural history and clinical features, as well as extracutaneous involvements such as hepatic IH, PHACES syndrome, and LUMBAR syndrome, are detailed. Complications such as ulceration, functional impairment, hypothyroidism, and cosmetic concerns are highlighted. The differential diagnosis and diagnostic modalities, including colorimeters, high-frequency ultrasonography, and imaging techniques, are discussed. Management approaches, including the use of propranolol, atenolol, corticosteroids, alternative systemic treatments, topical therapy, laser therapy, and surgery, are comprehensively reviewed. The evolving landscape of IH management is underscored, with ongoing research exploring alternative treatments and individualized approaches based on IH characteristics.
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Affiliation(s)
- Apoorva Sharma
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Manavi Gupta
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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2
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Gatts J, Chandra S, Krishnan D, Ricci K. Medical Management of Nonmalignant Vascular Tumors of the Head and Neck: Part 1. Oral Maxillofac Surg Clin North Am 2024; 36:103-113. [PMID: 37875385 DOI: 10.1016/j.coms.2023.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Vascular anomalies, broadly classified as nonmalignant tumors and malformations, consist of a multitude of disorders that have a wide range of symptoms and complications as well as overlapping clinical, radiologic, and histologic findings. Although usually difficult, distinguishing between nonmalignant vascular tumors and malformations, as well as the precise diagnosis within these distinctions, is critical because prognosis, therapy, and chronicity of care vary greatly. In contrast to normal endothelial turnover in vascular malformations, vascular tumors are characterized by the abnormal proliferation of endothelial cells and aberrant blood vessels.
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Affiliation(s)
- Jorie Gatts
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
| | - Srinivasa Chandra
- Department of Oral and Maxillofacial Surgery-Head and Neck Oncology and Microvascular Reconstruction, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Deepak Krishnan
- Department of Surgery, Section of Oral & Maxillofacial Surgery, University of Cincinnati, 200 Albert Sabin Way, ML 0461, Cincinnati, OH 45219, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA.
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3
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Mahajan M, Mahajan BB. Topical Timolol as a Therapeutic Modality in Severe Disfiguring Infantile Haemangioma. Indian J Dermatol 2024; 69:99-100. [PMID: 38572057 PMCID: PMC10986866 DOI: 10.4103/ijd.ijd_789_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Affiliation(s)
- Mohita Mahajan
- From the Department of Dermatology, Venereology and Leprosy, Government Medical College Amritsar, Punjab, India E-mail:
| | - Bharat Bhushan Mahajan
- From the Department of Dermatology, Venereology and Leprosy, Government Medical College Amritsar, Punjab, India E-mail:
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4
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DiDonna N, Khan K, Wood J. Infantile Scalp Hemangiomas: Surgical Management and Lessons Learned. J Craniofac Surg 2023:00001665-990000000-01191. [PMID: 37955432 DOI: 10.1097/scs.0000000000009816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/26/2023] [Indexed: 11/14/2023] Open
Abstract
Infantile hemangiomas (IH) are common benign vascular tumors in pediatric patients, often found on the scalp. While most IH naturally regress without intervention, surgical excision becomes necessary when severe anatomic or physiological complications arise. This review examines previously published case studies on pediatric scalp IH excisions, focusing on surgical outcomes and complications. A comprehensive search of the US National Library of Medicine National Institutes of Health (PubMed) database identified 19 relevant case studies. Most patients were female, with a wide age range at the time of excision. Various anatomic locations and sizes of the hemangiomas were observed. The reviewed literature demonstrates that surgical excision of scalp IH can be performed with minimal complications, even for sizable tumors. Successful outcomes and low complication rates highlight the effectiveness of surgical intervention in cases of life-threatening IH sequelae. Further research is warranted to explore optimal timing, techniques, and adjunct therapies for surgical management of scalp IH.
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Affiliation(s)
- Nicole DiDonna
- University of North Carolina School of Medicine, University of North Carolina
| | - Kamran Khan
- Division of Plastic & Reconstructive Surgery, University of North Carolina, Chapel Hill, NC
| | - Jeyhan Wood
- Division of Plastic & Reconstructive Surgery, University of North Carolina, Chapel Hill, NC
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5
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Freiha M, Achim M, Gheban BA, Moldovan R, Filip GA. In Vivo Study of the Effects of Propranolol, Timolol, and Minoxidil on Burn Wound Healing in Wistar Rats. J Burn Care Res 2023; 44:1466-1477. [PMID: 37099384 DOI: 10.1093/jbcr/irad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Indexed: 04/27/2023]
Abstract
Propranolol, timolol, and minoxidil have all shown benefits in treatment of burn injury and other skin wounds. The study evaluated their effects on full-thickness thermal skin burns in a Wistar rat model. Performed on 50 female rats; two dorsal skin burns were created on each animal. On the next day, the rats were divided into 5 groups (n = 10); each has received a specific treatment daily for 14 days: group I-topical vehicle (control), group II-topical silver sulfadiazine (SSD), group III-oral propranolol (5.5 mg) associated with topical vehicle, group IV-topical timolol 1% cream, and group V-topical minoxidil 5% cream. Wound contraction rates, malondialdehyde (MDA), glutathione (GSH, GSSG), and catalase activity in skin and/or serum were evaluated, and histopathological analyses were performed. Propranolol did not show advantages in necrosis prevention and wound contraction and healing, and did not reduce oxidative stress. It impaired keratinocyte migration, and promoted ulceration, chronic inflammation, and fibrosis, yet reducing the necrotic zone. Timolol prevented necrosis and promoted contraction and healing, increased antioxidant capacity and promoted keratinocyte migration and neo capillarization in comparison to the other treatments. Minoxidil reduced necrosis and enhanced contraction, resulting in positive outcomes after 1 week of treatment regarding local antioxidant defense, keratinocyte migration, neo capillarization, chronic inflammation, and fibrosis rates. However, after 2 weeks, it resulted in contrasting outcomes. In conclusion, topical timolol promoted wound contraction and healing, reducing local oxidative stress and improving keratinocyte migration, bringing arguments for potential benefits in skin epithelization.
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Affiliation(s)
- Michel Freiha
- Department of Physiology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Marcela Achim
- Department of Pharmaceutical Technology and Biopharmaceutics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Bogdan-Alexandru Gheban
- Department of Anatomic Pathology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Remus Moldovan
- Department of Physiology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gabriela Adriana Filip
- Department of Physiology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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6
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Tiwari P, Pandey V, Bera RN, Tiwary N, Mishra A, Sharma SP. Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e499-e505. [PMID: 35217221 DOI: 10.1016/j.jormas.2022.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/15/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
RATIONALE Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management. METHODS Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value <0.05 was taken as significant. RESULTS In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049). CONCLUSION Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.
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Affiliation(s)
- Preeti Tiwari
- Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University Varanasi 221005, India
| | - Vaibhav Pandey
- Department of Pediatric surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
| | - Rathindra Nath Bera
- Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University Varanasi 221005, India.
| | - Narendra Tiwary
- Department of Community Medicine, RG KAR medical college and hospital, Kolkata, India
| | - Akash Mishra
- Department of Pediatric surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
| | - Shiv Prasad Sharma
- Department of Pediatric surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India
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7
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Yu DA, Min SH, Song J, Park JS, Lee H, Ohn J, Kim KH. Good Clinical Responders to Topical Timolol in Patients with Infantile Hemangiomas: A 7-Year Retrospective Study of 328 Korean Patients. Ann Dermatol 2022; 34:360-369. [PMID: 36198627 PMCID: PMC9561300 DOI: 10.5021/ad.21.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 05/06/2022] [Accepted: 05/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background Topical timolol is widely used for treatment of superficial infantile hemangioma (IH). However, little is known about factors that affect the response to topical timolol treatment. Objective This study aimed to investigate the efficacy, safety, and predictive value for good response to topical timolol for IH. Methods A retrospective review of medical records and clinical photos of 328 patients with IH treated with topical timolol 0.5% solution was conducted. Serial clinical photographs were compared with those at the initial visit using a 100-mm visual analogue scale (VAS). Treatment response was defined as an improvement of at least 75% from baseline in IH lesions within 12 months of treatment. Results Overall, IH patients treated with topical timolol showed significant improvement from baseline, showing that the final VAS score within 12 months of treatment was 69.7±20.4. The multivariable logistic regression analysis showed age at initiation of treatment (p=0.007), length of gestation and fetal growth (p=0.03), depth (p=0.01), and flexural area (p=0.007) were significantly associated with treatment response. Only four patients (1.1%) reported local irritation. Conclusion This study demonstrated that topical timolol treatment was an effective and well-tolerated treatment for IHs. Physicians are encouraged to consider several patient- or lesional factors that might affect treatment response to achieve better clinical outcomes.
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Affiliation(s)
- Da-Ae Yu
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hee Min
- Department of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jaeryong Song
- Department of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jong Seo Park
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Hanjae Lee
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Jungyoon Ohn
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Han Kim
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
- Laboratory of Cutaneous Aging and Hair Research, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
- Institute of Human Environment Interface Biology, Seoul National University College of Medicine, Seoul, Korea
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8
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Abstract
Infantile hemangioma (IH) is the most common benign vascular tumor of infancy, affecting about 5% of infants. It has a characteristic growth pattern of early rapid proliferation followed by progressive involution. Although most IH evolve favorably, complications are observed in 10-15% of cases, justifying treatment. For over 10 years now, propranolol has become the first-line therapy for complicated IH, revolutionizing their management and their prognosis. In this article, we review the clinical features, associations, complications/sequelae and therapeutic approaches for IH, focusing on current medical therapy. Indications for treatment and various treatment options, including propranolol and other oral β-blockers, topical timolol, and corticosteroids are presented. Current controversies regarding oral propranolol such as pre-treatment screening, in- vs out-patient initiation of treatment, early and potential long-term side effects and recommended monitoring are discussed.
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Affiliation(s)
- Caroline Colmant
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada.
| | - Julie Powell
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
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9
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Alzaid M, Al-Naseem A, Al-Niaimi F, Ali FR. Topical timolol in dermatology: infantile hemangiomas and beyond. Clin Exp Dermatol 2021; 47:819-832. [PMID: 34798680 DOI: 10.1111/ced.15021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022]
Abstract
Timolol, a non-selective β-adrenergic receptor blocker, is well-tolerated and is becoming increasingly popular in dermatology especially after its use in the management of infantile hemangiomas. Its effects are mainly due to vasoconstriction, inhibition of angiogenesis and keratinocyte migration promotion for re-epithelialization and wound healing. We review the evidence behind the use of timolol in several dermatological conditions including infantile hemangiomas, pyogenic granulomas, Kaposi's sarcoma, chronic wound healing, post-surgical wounds, acne vulgaris, rosacea, eczema and red scrotum syndrome.
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Affiliation(s)
- M Alzaid
- University of Manchester Medical School, Manchester, UK
| | - A Al-Naseem
- University of Manchester Medical School, Manchester, UK
| | - F Al-Niaimi
- Department of Dermatology, Aalborg University Hospital, Aalborg, Denmark
| | - F R Ali
- Mid Cheshire NHS Foundation Trust, Macclesfield, UK.,Dermatological Surgery & Laser Unit, St John's Institute of Dermatology, Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
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10
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Wu J, Zhou F, Gao Y. Efficacy Evaluation of 755-nm Long-Pulse Alexandrite Laser Combined with 0.5% Timolol Maleate Eye Drops in the Treatment of Thicker Infantile Hemangioma. Clin Cosmet Investig Dermatol 2021; 14:1621-1628. [PMID: 34785921 PMCID: PMC8590841 DOI: 10.2147/ccid.s330411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/12/2021] [Indexed: 11/23/2022]
Abstract
Purpose Assessment of the clinical effectiveness and safety of 755-nm long-pulse alexandrite laser combined with 0.5% timolol maleate eye drops in treating thicker infantile hemangioma (IH). Materials and Methods Retrospective analysis of IH treated with 755-nm long-pulse alexandrite laser and topical timolol in the Second Affiliated Hospital of Wenzhou Medical University from October 2019 to October 2020. Seventy-eight cases were included, with a five-week laser treatment interval. Treatment status was documented during the 35 weeks before each treatment, the effect was assessed at the visual analog scale (VAS), and side effects were recorded. During the 6-month follow-up period, the recurrence and residual skin lesions were monitored. The relationship between IH thickness, treatment duration and VAS was analyzed. Results Among the 78 children with hemangioma, 4 children were treated with a combination of propranolol, fractional laser and cinnamyl alcohol injection due to poor curative effect. Finally, the lesions were effectively alleviated. At the 5th, 15th, 25th, and 35th weeks of treatment, the average VAS of 74 children were 3.56 ± 1.20, 4.61 ± 1.43, 5.63 ± 1.60, and 6.63 ± 1.72, respectively. We analyzed VAS in different thickness groups with Repeated Measures Analysis of Variance(RMANOVA). The results show that the VAS of the thickness 2–3 mm and 3–5mm groups were higher than the 5–7mm and 7–8mm groups (F group = 440.54, P <0.05, F time = 448.31, P <0.05). During the 6-month follow-up period, none of the 74 children relapsed and the residual skin lesions gradually vanished. Conclusion Combined treatment of IHs with a 755-nm long-pulse alexandrite laser and 0.5% timolol maleate eye drops which has apparent clinical efficacy and safety reduce residual skin lesions and decrease the IH recurrence rate.
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Affiliation(s)
- Jianming Wu
- Department of Dermatological, Yuying Children's Hospital, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Fangyan Zhou
- Department of Dermatological, Yuying Children's Hospital, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Yu Gao
- Department of Dermatological, Yuying Children's Hospital, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
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11
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Kowalska M, Dębek W, Matuszczak E. Infantile Hemangiomas: An Update on Pathogenesis and Treatment. J Clin Med 2021; 10:4631. [PMID: 34682753 PMCID: PMC8539430 DOI: 10.3390/jcm10204631] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/25/2021] [Accepted: 10/05/2021] [Indexed: 12/13/2022] Open
Abstract
Infantile hemangiomas are the most common benign vascular tumors in infancy. This review includes an update on the current knowledge on pathogenesis, a discussion on indications for treatment, and a review of the mechanisms underlying the different treatment methods. Although most infantile hemangiomas require only active observation because of their natural course, which results in involution, about 10% present with complications that require immediate treatment. The basic treatment includes systemic and topical options. In cases of insufficient response or rebound growth, other forms of treatment should be considered. In some cases, combined therapy might be initiated.
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Affiliation(s)
- Małgorzata Kowalska
- Department of Pediatric Surgery and Pediatric Urology, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (W.D.); (E.M.)
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12
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Cuenca-Barrales C, Baselga-Torres E, del Boz-González J, Vicente A, Palencia-Pérez S, Campos-Domínguez M, Valdivieso-Ramos M, Martín-Santiago A, Montserrat-García M, Azón-Masoliver A, Feito-Rodríguez M, Domínguez-Cruz J, Roé-Crespo E, Salas-Márquez C, Giacaman A, Lorente-Lavirgen A, Quintana-Castanedo L, de Vega-Martínez M, García-Doval I, Bernabéu-Wittel J. Baseline Description of the Spanish Academy of Dermatology Infantile Haemangioma Nationwide Prospective Cohort. Comparison of Patients Treated with Propranolol in Routine Clinical Practice with Previous Pivotal Clinical Trial Data. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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13
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Sip S, Paczkowska-Walendowska M, Rosiak N, Miklaszewski A, Grabańska-Martyńska K, Samarzewska K, Cielecka-Piontek J. Chitosan as Valuable Excipient for Oral and Topical Carvedilol Delivery Systems. Pharmaceuticals (Basel) 2021; 14:ph14080712. [PMID: 34451809 PMCID: PMC8401298 DOI: 10.3390/ph14080712] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/20/2021] [Accepted: 07/20/2021] [Indexed: 01/28/2023] Open
Abstract
Chitosan is a valued excipient due to its biocompatibility properties and increasing solubility of poorly water-soluble drugs. The research presented in this paper concerns the preparation of binary combinations of chitosan (deacetylated chitin) with carvedilol (beta-blocker) to develop a formulation with a modified carvedilol release profile. As part of the research, six physical mixtures of chitosan with carvedilol were obtained and identified by spectral (PXRD, FT-IR, and Raman), thermal (DSC), and microscopic (SEM) methods. The next stage of the research estimated the profile changes and the dissolution rate for carvedilol in the obtained drug delivery systems; the reference sample was pure carvedilol. The studies were conducted at pH = 1.2 and 6.8, simulating the gastrointestinal tract conditions. Quantitative changes of carvedilol were determined using the developed isocratic UHPLC-DAD method. Established apparent permeability coefficients proved the changes in carvedilol's permeability after introducing a drug delivery system through membranes simulating the gastrointestinal tract and skin walls. A bioadhesive potential of carvedilol-chitosan systems was confirmed using the in vitro model. The conducted research and the obtained results indicate a significant potential of using chitosan as an excipient in modern oral or epidermal drug delivery systems of carvedilol.
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Affiliation(s)
- Szymon Sip
- Department of Pharmacognosy, Poznan University of Medical Sciences, 4 Swiecickiego Street, 60-781 Poznan, Poland; (S.S.); (M.P.-W.); (N.R.)
| | - Magdalena Paczkowska-Walendowska
- Department of Pharmacognosy, Poznan University of Medical Sciences, 4 Swiecickiego Street, 60-781 Poznan, Poland; (S.S.); (M.P.-W.); (N.R.)
| | - Natalia Rosiak
- Department of Pharmacognosy, Poznan University of Medical Sciences, 4 Swiecickiego Street, 60-781 Poznan, Poland; (S.S.); (M.P.-W.); (N.R.)
| | - Andrzej Miklaszewski
- Institute of Materials Science and Engineering, Poznan University of Technology, Jana Pawła II 24, 61-138 Poznan, Poland;
| | | | - Karolina Samarzewska
- Department of Clinical Auxiology and Pediatric Nursing, Poznan University of Medical Sciences, Szpitalna 27/33 Street, 60-572 Poznan, Poland;
| | - Judyta Cielecka-Piontek
- Department of Pharmacognosy, Poznan University of Medical Sciences, 4 Swiecickiego Street, 60-781 Poznan, Poland; (S.S.); (M.P.-W.); (N.R.)
- Correspondence:
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14
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Behera B, Remya R, Chandrashekar L, Thappa DM, Gochhait D. Tufted angioma successfully treated with topical timolol gel-forming solution. Indian J Dermatol Venereol Leprol 2021; 87:581-584. [PMID: 34219431 DOI: 10.25259/ijdvl_822_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/01/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Biswanath Behera
- Department of Dermatology, and Venereology, AIIMS, Bhubaneswar, Odisha, India
| | - Raj Remya
- Department of Dermatology, Venereology and Leprology, Pondicherry Institute of Medical Sciences, Puducherry, India
| | | | - Devinder Mohan Thappa
- Department of Dermatology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
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15
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Filoni A, Ambrogio F, De Marco A, Pacifico A, Bonamonte D. Topical beta-blockers in dermatologic therapy. Dermatol Ther 2021; 34:e15016. [PMID: 34075667 PMCID: PMC8459235 DOI: 10.1111/dth.15016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/24/2021] [Indexed: 12/25/2022]
Abstract
An increasing use of beta-blockers in dermatology has been described over the last 10 years, despite the fact that their use in diseases other than infantile hemangiomas is off-label. This review discusses the emerging role of topical beta-blockers in the treatment of infantile hemangioma, but also pyogenic granuloma, Kaposi sarcoma, wounds and nail paronychia. Data in literature demonstrate that topical beta-blockers are a safe and valid therapeutic option in numerous cutaneous diseases. Side effects are mainly restricted to the application site. Further studies and randomized trials may contribute to reinforce the role of topical beta-blockers in the dermatological armamentarium.
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Affiliation(s)
- Angela Filoni
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy.,Section of Dermatology, Perrino Hospital, Brindisi, Italy
| | - Francesca Ambrogio
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Aurora De Marco
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Alessia Pacifico
- Phototherapy Unit, San Gallicano Dermatological Institute, Rome, Italy
| | - Domenico Bonamonte
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
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Cuenca-Barrales C, Baselga-Torres E, Del Boz-González J, Vicente A, Palencia-Pérez SI, Campos-Domínguez M, Valdivieso-Ramos M, Martín-Santiago A, Montserrat-García MT, Azón-Masoliver A, Feito-Rodríguez M, Domínguez-Cruz JJ, Roé-Crespo E, Salas-Márquez C, Giacaman A, Lorente-Lavirgen AI, Quintana-Castanedo L, de Vega-Martínez M, García-Doval I, Bernabéu-Wittel J. Baseline description of the Spanish Academy of Dermatology infantile haemangioma nationwide prospective cohort. Comparison of patients treated with propranolol in routine clinical practice with previous pivotal clinical trial data. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00198-8. [PMID: 34052200 DOI: 10.1016/j.ad.2021.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND There are several therapeutic options for infantile haemangiomas (IH). Propranolol is used according to a pivotal trial. We aimed to describe the characteristics of IH in clinical practice, including the therapies used, and to compare the characteristics of patients treated with propranolol with those of the trial to assess its external validity. METHODS Consecutive patients attending 12 Spanish hospitals from June 2016 to October 2019 were included (n=601). RESULTS The mean age was 3.9 (SD:1.9) months, with a 2:1 female-to-male ratio. Most IHs were localized (82%, 495), superficial (64%, 383) and located in the face (25%, 157) and trunk (31%, 188). Median size was 17 (IR: 10-30) x 12 (IR: 7-20) mm. Complications were found in 16 (3%) patients. Treatment was initiated for 52% (311). Most patients received timolol (76%, 237); propranolol was reserved for complications or high-risk IHs. Aesthetic impairment was the main reason for starting therapy (64%, 199). Several characteristics of the patients and IHs treated with propranolol are similar to those of the pivotal clinical trial, but 1/3 of IHs did not reach the minimum diameter to meet the inclusion criteria, and important prognostic information was not reported. CONCLUSIONS As most patients receive treatment for aesthetic impairment, there is a need to better understand the aesthetic results of therapies and to increase evidence on the use of timolol, which is currently the most common therapy. Propranolol is being used in a population generally similar to that of the trial; however, this statement cannot be definitely confirmed.
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Affiliation(s)
- C Cuenca-Barrales
- Unidad de investigación, Fundación Piel Sana Academia Española de Dermatología y Venereología, Madrid, España; Departamento de Dermatología, Hospital Universitario Virgen de las Nieves, Granada, España; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, España.
| | - E Baselga-Torres
- Departamento de Dermatología, Hospital Sant Joan de Déu, Barcelona, España; Clínica Dermik, Barcelona, España
| | - J Del Boz-González
- Departamento de Dermatología, Hospital Costa del Sol, Marbella, Málaga, España
| | - A Vicente
- Departamento de Dermatología, Hospital Sant Joan de Déu, Barcelona, España
| | | | | | | | - A Martín-Santiago
- Departamento de Dermatología, Hospital Son Espases, Palma de Mallorca, España
| | - M T Montserrat-García
- Departamento de Dermatología, Hospital Virgen del Rocío, Sevilla, España; Departamento de Dermatología, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España
| | - A Azón-Masoliver
- Departamento de Dermatología, Hospital Sant Joan de Reus, Tarragona, España
| | | | - J J Domínguez-Cruz
- Departamento de Dermatología, Hospital Virgen del Rocío, Sevilla, España; Departamento de Dermatología, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España
| | - E Roé-Crespo
- Departamento de Dermatología, Hospital Santa Creu i Sant Pau, Barcelona, España
| | - C Salas-Márquez
- Departamento de Dermatología, Hospital Costa del Sol, Marbella, Málaga, España
| | - A Giacaman
- Departamento de Dermatología, Hospital Son Espases, Palma de Mallorca, España
| | - A I Lorente-Lavirgen
- Departamento de Dermatología, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España
| | | | - M de Vega-Martínez
- Unidad de investigación, Fundación Piel Sana Academia Española de Dermatología y Venereología, Madrid, España
| | - I García-Doval
- Unidad de investigación, Fundación Piel Sana Academia Española de Dermatología y Venereología, Madrid, España; Departamento de Dermatología, Complexo Hospitalario Universitario de Vigo, España
| | - J Bernabéu-Wittel
- Departamento de Dermatología, Hospital Virgen del Rocío, Sevilla, España; Departamento de Dermatología, Hospital Viamed Santa Ángela de la Cruz, Sevilla, España
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Tourlaki A, Maronese CA, Brambilla L. Successful treatment of conjunctival classic Kaposi's sarcoma with topical timolol. Ital J Dermatol Venerol 2021; 156:629-630. [PMID: 33890730 DOI: 10.23736/s2784-8671.21.06854-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Athanasia Tourlaki
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo A Maronese
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy - .,Department of Physiopathology and Transplantation, University of Milan, Milan, Italy
| | - Lucia Brambilla
- Unit of Dermatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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18
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Goodarzi A, Mozafarpoor S, Dodangeh M, Seirafianpour F, Shahverdi MH. The role of topical timolol in wound healing and the treatment of vascular lesions: A narrative review. Dermatol Ther 2021; 34:e14847. [PMID: 33538017 DOI: 10.1111/dth.14847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/30/2020] [Accepted: 01/23/2021] [Indexed: 12/12/2022]
Abstract
Beta-2 adrenergic receptors are the only subgroup of beta-adrenergic receptors expressed in the membrane of large cells, including skin keratinocytes, fibroblasts, and melanocytes. Alterations in the function or concentration of β2 adrenoreceptors related to keratinocytes are associated with some skin conditions. Some findings suggest the role of β2 adrenoreceptors in maintaining the function and integrity of the epidermis. Beta-receptor antagonists can be systemically and topically effective in healing hemangioma, paronychia, vasculitis ulcer, tufted angioma, acute and chronic wounds. Most studies with a strong design on this subject deal with the systemic form, but recently, numerous case and group reports and smaller studies have focused on topical forms, especially topical timolol. The present comprehensive review study surveys the role of topical timolol in acute and chronic wound healing in the field of dermatology.
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Affiliation(s)
- Azadeh Goodarzi
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Samaneh Mozafarpoor
- Department of Dermatology, Skin Disease and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Milad Dodangeh
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farnoosh Seirafianpour
- Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohamad Hasan Shahverdi
- Department of Dermatology, Rasool Akram Medical Complex, Iran University of Medical Sciences (IUMS), Tehran, Iran
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Yoon DJ, Kaur R, Gallegos A, West K, Yang H, Schaefer S, Tchanque-Fossuo C, Dahle SE, Isseroff RR. Repurposing Ophthalmologic Timolol for Dermatologic Use: Caveats and Historical Review of Adverse Events. Am J Clin Dermatol 2021; 22:89-99. [PMID: 33237496 DOI: 10.1007/s40257-020-00567-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2020] [Indexed: 01/13/2023]
Abstract
Ophthalmic timolol solution is increasingly being repurposed as a topical therapeutic for a variety of dermatologic diseases, including pyogenic granulomas, infantile hemangiomas, and chronic wounds. There are no published guidelines or protocols for use in these indications in adults, and the dermatologic community may not be familiar with adverse events that have been extensively documented relating to its ophthalmic use. We review the evidence available relating to adverse events to topical timolol use to evaluate its safety in dermatologic applications and to alert clinicians to screening and monitoring that is needed when repurposing this drug for dermatologic use. The majority of serious adverse events associated with ophthalmic timolol were reported in the first 7 years of use, between 1978 and 1985, of which most common were cardiovascular and respiratory events, but also included 32 deaths. The available evidence suggests that ophthalmic timolol safety profiling may have been incomplete prior to widespread use. Recent clinical trials for dermatologic indications have focused on documenting efficacy and have not had rigorous monitoring for potential adverse events. Topical timolol may be safe and effective for the treatment of various dermatologic conditions in patients whose medical histories have been carefully reviewed for evidence of pre-existing cardiac or pulmonary disease and are monitored for potential adverse events. Despite the wide use of timolol in ophthalmologic practice, safe dermatologic repurposing requires recognition of the potential for facilitated systemic absorption though the skin and appreciation of its history of adverse events.
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Affiliation(s)
- Daniel J Yoon
- Department of Dermatology, University of California Davis School of Medicine, Institute for Regenerative Cures, 2921 Stockton Blvd, Ste 1630, Sacramento, CA, 95817, USA
- Dermatology Service, VA Northern California Health Care System, Mather, CA, USA
| | - Ramanjot Kaur
- Dermatology Service, VA Northern California Health Care System, Mather, CA, USA
| | - Anthony Gallegos
- Department of Dermatology, University of California Davis School of Medicine, Institute for Regenerative Cures, 2921 Stockton Blvd, Ste 1630, Sacramento, CA, 95817, USA
| | - Kaitlyn West
- Dermatology Service, VA Northern California Health Care System, Mather, CA, USA
| | - Hsinya Yang
- Department of Dermatology, University of California Davis School of Medicine, Institute for Regenerative Cures, 2921 Stockton Blvd, Ste 1630, Sacramento, CA, 95817, USA
| | - Saul Schaefer
- Department of Internal Medicine, University of California School of Medicine, Davis, CA, USA
| | | | - Sara E Dahle
- Department of Dermatology, University of California Davis School of Medicine, Institute for Regenerative Cures, 2921 Stockton Blvd, Ste 1630, Sacramento, CA, 95817, USA
- Podiatry Section, VA Northern California Health Care System, Mather, CA, USA
| | - R Rivkah Isseroff
- Department of Dermatology, University of California Davis School of Medicine, Institute for Regenerative Cures, 2921 Stockton Blvd, Ste 1630, Sacramento, CA, 95817, USA.
- Dermatology Service, VA Northern California Health Care System, Mather, CA, USA.
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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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21
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Hota D, Borkar N, Sharma A. Complicated infantile hemangioma successfully treated with topical timolol 0.5% solution: A case report. J Cutan Aesthet Surg 2021; 14:440-442. [PMID: 35283589 PMCID: PMC8906260 DOI: 10.4103/jcas.jcas_69_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Infantile hemangiomas (IHs) are common benign lesions involving most part of the body. It can regress spontaneously but these hemangiomas should be treated early on course of evolution to prevent further complications. Different treatment options are available for its management. Topical timolol 0.5% solution available as eye drops or gel can be used as first-line therapy even in complicated IH. We have successfully treated a large complicated facial IH by using topical timolol 0.5% solution.
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Qiao J, Lin J, Zhang D, Li J, Chen C, Yu H, Li X, Fang B. Efficacy of Combined Topical Timolol and Oral Propranolol for Treating Infantile Hemangioma: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2020; 11:554847. [PMID: 33132908 PMCID: PMC7578425 DOI: 10.3389/fphar.2020.554847] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/31/2020] [Indexed: 11/21/2022] Open
Abstract
Background Oral propranolol has become the first-line treatment for infantile hemangioma (IH). However, combined therapy with topical timolol and oral propranolol has been proposed as a more effective IH treatment strategy. We aimed to compare the safety and efficacy of topical timolol, oral propranolol, and their combination for treating IH in a meta-analysis. Methods Relevant randomized controlled trials (RCTs) were obtained after searching the PubMed, Embase, Cochrane’s Library, China National Knowledge Infrastructure, and WanFang databases. A random-effect model was used to pool the results. Results Eight RCTs with 759 patients with IH were included in this meta-analysis. Treatment with topical timolol alone showed a similar response rate compared to oral propranolol (risk ratio [RR] = 0.97, p = 0.63), but resulted in fewer adverse events (RR = 0.36, p = 0.002). Combined treatment with topical timolol and oral propranolol showed a favorable response rate compared to treatment with oral propranolol (RR = 1.14, p = 0.03) or topical timolol (RR = 1.36, p = 0.01) alone. Moreover, combined treatment showed similar risks of adverse events compared to oral propranolol (RR = 0.80, p = 0.24) or topical timolol (RR = 1.31, p = 0.25) alone. Conclusions Combined treatment with topical timolol and oral propranolol may be more effective than either single treatment strategy in patients with IH. Topical timolol alone conferred similar efficacy for IH compared to oral propranolol, but with less incidence of adverse events.
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Affiliation(s)
- Junbo Qiao
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junjie Lin
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dexin Zhang
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junhua Li
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Changkuan Chen
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongye Yu
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaodi Li
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bin Fang
- Department of Hemangioma Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Wang X, Feng W, Zhao X, Liu Z, Dong L. The Efficacy and Safety of Topical β-Blockers in Treating Infantile Hemangiomas: A Meta-Analysis Including 11 Randomized Controlled Trials. Dermatology 2020; 237:433-443. [PMID: 33027794 PMCID: PMC8117385 DOI: 10.1159/000510029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of topical β-blockers in the treatment of superficial infantile hemangiomas (SIH) and mixed infantile hemangiomas (MIH), respectively, and compare the efficacy and safety of topical β-blockers with other interventions. METHODS The PRISMA guidelines were adhered to. We searched for randomized controlled trials in databases from 2010 to 2018 comparing topical β-blockers with other interventions for infantile hemangiomas. The outcomes evaluated were efficacy and adverse effects. Data analyses were performed using RevMan 5.3. Publication bias was assessed to account for bias in patient selection. RESULTS Eleven studies, involving 1,235 patients, were subjected to this meta-analysis. Six studies compared topical β-blockers with other interventions (propranolol, placebo, corticosteroids or pulsed dye laser) in treating SIH, and 5 studies evaluated the efficacy and safety of a topical β-blocker when it was combined with another intervention in treating MIH. A topical β-blocker was discovered to be as effective as oral propranolol in treating SIH (risk ratio, RR, 0.96, 95% confidence interval, CI, 0.91-1.02, p = 0.20, I2 = 0%), and topical β-blockers were more beneficial than placebo, corticosteroids or pulsed dye laser in treating SIH (RR 2.25, 95% CI 1.66-3.05, p < 0.00001, I2 = 0%). Topical β-blockers combined with another intervention gave rise to a better clinical response in the treatment of MIH than intervention alone (RR 1.99, 95% CI 1.10-3.60, p = 0.02, I2 = 55%) (standard mean difference 0.80, 95% CI 0.28-1.31, p = 0.002, I2 = 0%). Compared with oral propranolol, topical β-blockers were associated with fewer incidences of adverse effects (RR 0.05, 95% CI 0.01-0.39, p = 0.004, I2 = 0%). No significant difference in adverse effects was found when a topical β-blocker was combined with another intervention in treating MIH (RR 1.01, 95% CI 0.58-1.74, p = 0.98, I2 = 0%). CONCLUSIONS This meta-analysis provided evidence that topical β-blockers may replace oral propranolol as first-line therapy for SIH and that they are of additive value in treating MIH.
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Affiliation(s)
- Xinhui Wang
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Wei Feng
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Xufeng Zhao
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Ziyu Liu
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Liang Dong
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, China,*Liang Dong, E-Mail
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Baker JG, Fromont C, Bruder M, Thompson KSJ, Kellam B, Hill SJ, Gardiner SM, Fischer PM. Using Esterase Selectivity to Determine the In Vivo Duration of Systemic Availability and Abolish Systemic Side Effects of Topical β-Blockers. ACS Pharmacol Transl Sci 2020; 3:737-748. [PMID: 32832874 DOI: 10.1021/acsptsci.0c00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Indexed: 11/30/2022]
Abstract
For disorders of the skin, eyes, ears, and respiratory tract, topical drugs, delivered directly to the target organ, are a therapeutic option. Compared with systemic oral therapy, the benefits of topical treatments include a faster onset of action, circumventing the liver first pass drug metabolism, and reducing systemic side effects. Nevertheless, some systemic absorption still occurs for many topical agents resulting in systemic side effects. One way to prevent these would be to develop drugs that are instantly degraded upon entry into the bloodstream by serum esterases. Because topical β-blockers are used in glaucoma and infantile hemeangioma and cause systemic side effects, the β-adrenoceptor system was used to test this hypothesis. Purified liver esterase reduced the apparent affinity of esmolol, an ester-containing β-blocker used in clinical emergencies, for the human β-adrenoceptors in a concentration and time-dependent manner. However, purified serum esterase had no effect on esmolol. Novel ester-containing β-blockers were synthesized and several were sensitive to both liver and serum esterases. Despite good in vitro affinity, one such compound, methyl 2-(3-chloro-4-(3-((2-(3-(3-chlorophenyl)ureido)ethyl)amino)-2-hydroxypropoxy)phenyl)acetate, had no effect on heart rate when injected intravenously into rats, even at 10 times the equipotent dose of esmolol and betaxolol that caused short and sustained reductions in heart rate, respectively. Thus, ester-based drugs, sensitive to serum esterases, offer a mechanism for developing topical agents that are truly devoid of systemic side effects. Furthermore, differential susceptibility to liver and serum esterases degradation may also allow the duration of systemic availability for other drugs to be fine-tuned.
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Affiliation(s)
- Jillian G Baker
- Cell Signalling Research Group, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K.,Centre of Membrane Proteins and Receptors, University of Birmingham and University of Nottingham, The Midlands, U.K
| | - Christophe Fromont
- School of Pharmacy and Centre for Biomedical Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K
| | - Marjorie Bruder
- Centre of Membrane Proteins and Receptors, University of Birmingham and University of Nottingham, The Midlands, U.K
| | - Kevin S J Thompson
- Cell Signalling Research Group, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K
| | - Barrie Kellam
- Centre of Membrane Proteins and Receptors, University of Birmingham and University of Nottingham, The Midlands, U.K.,School of Pharmacy and Centre for Biomedical Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K
| | - Stephen J Hill
- Cell Signalling Research Group, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K.,Centre of Membrane Proteins and Receptors, University of Birmingham and University of Nottingham, The Midlands, U.K
| | - Sheila M Gardiner
- Cell Signalling Research Group, Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K
| | - Peter M Fischer
- Centre of Membrane Proteins and Receptors, University of Birmingham and University of Nottingham, The Midlands, U.K.,School of Pharmacy and Centre for Biomedical Sciences, University of Nottingham, Nottingham, NG7 2RD, U.K
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Mashiah J, Bar-Ilan E, Koren A, Friedman O, Zur E, Artzi O. Enhanced Percutaneous Delivery of Beta-Blockers Using Thermal Resurfacing Drug Delivery System for Topical Treatment of Infantile Hemangiomas. Dermatology 2020; 236:565-570. [DOI: 10.1159/000507808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/03/2020] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Infantile hemangiomas (IHs) are the most common vascular tumors in children. In the past few years, topical beta-blockers (bBs) have been reported to be an effective treatment of superficial IHs. <b><i>Objective:</i></b> We sought to evaluate the clinical effectiveness and safety profile of enhanced percutaneous delivery of bBs for the treatment of IH. <b><i>Methods:</i></b> A retrospective study of all cases of IHs treated with enhanced percutaneous delivery of bBs between 2018 and 2019 was performed. Epidemiologic, clinical, and treatment data, including effectiveness score and safety, were reviewed. <b><i>Results:</i></b> The study included 11 patients with a total of 11 IHs. Of the total number of IHs, 7 (63.7%) showed a good response to treatment and 4 (36.3%) had a partial response; thus all patients (100%) had good or partial response to treatment. No systemic or local adverse effects were reported. <b><i>Limitations:</i></b> This is an uncontrolled retrospective study. <b><i>Conclusion:</i></b> Enhanced percutaneous delivery of bBs is a safe and efficient topical therapy for IH.
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Chen ZY, Wang QN, Zhu YH, Zhou LY, Xu T, He ZY, Yang Y. Progress in the treatment of infantile hemangioma. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:692. [PMID: 31930093 PMCID: PMC6944559 DOI: 10.21037/atm.2019.10.47] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023]
Abstract
Infantile hemangioma (IH) is a common benign tumor, which mostly resolves spontaneously; however, children with high-risk IH need treatment. Currently, the recognized first-line treatment regimen for IH is oral propranolol, but research on the pathogenesis of IH has led to the identification of new therapeutic targets, which have shown good curative effects, providing more options for disease treatment. This article summarizes the applications of different medications, dosages, and routes of administration for the treatment of IH. In addition to drug therapy, this article also reviews current therapeutic options for IH such as laser therapy, surgical treatment, and observation. To provide the best treatment, therapeutic regimens for IH should be selected based on the child's age, the size and location of the lesion, the presence of complications, the implementation conditions, and the potential outcomes of the treatment.
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Affiliation(s)
- Zhao-Yang Chen
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Qing-Nan Wang
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Yang-Hui Zhu
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Ling-Yan Zhou
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Ting Xu
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Zhi-Yao He
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Yang Yang
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
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Abstract
Infantile haemangioma (IH) are the most frequent skin tumors in childhood. The diagnosis is usually established from the clinical picture and typical course of growth. Sectional imaging procedures are indicated in segmental, especially facial haemangiomas. The vast majority of IH are uncomplicated and do not require any treatment. In complicated IH, treatment should be initiated as soon as possible in order to avoid permanent damage. Propranolol is the treatment of choice for complicated IH.
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Affiliation(s)
- Antonia Reimer
- Klinik für Dermatologie und Venerologie, Universitätsklinikum Freiburg, Hauptstr. 7, 79104, Freiburg, Deutschland.
| | - Hagen Ott
- Fachbereich Pädiatrische Dermatologie und Allergologie, Kinder- und Jugendkrankenhaus AUF DER BULT, Janusz-Korczak-Allee 12, 30173, Hannover, Deutschland
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Bovbjerg ML. Current Resources for Evidence-Based Practice, March 2019. J Obstet Gynecol Neonatal Nurs 2019; 48:230-248. [PMID: 30735623 DOI: 10.1016/j.jogn.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
A review of new resources to support the provision of evidence-based care for women and infants.
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Novoa M, Baselga E, Beltran S, Giraldo L, Shahbaz A, Pardo‐Hernandez H, Arevalo‐Rodriguez I. Interventions for infantile haemangiomas of the skin. Cochrane Database Syst Rev 2018; 4:CD006545. [PMID: 29667726 PMCID: PMC6513200 DOI: 10.1002/14651858.cd006545.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infantile haemangiomas (previously known as strawberry birthmarks) are soft, raised swellings of the skin that occur in 3% to 10% of infants. These benign vascular tumours are usually uncomplicated and tend to regress spontaneously. However, when haemangiomas occur in high-risk areas, such as near the eyes, throat, or nose, impairing their function, or when complications develop, intervention may be necessary. This is an update of a Cochrane Review first published in 2011. OBJECTIVES To assess the effects of interventions for the management of infantile haemangiomas in children. SEARCH METHODS We updated our searches of the following databases to February 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, LILACS, and CINAHL. We also searched five trials registries and checked the reference lists of included studies for further references to relevant trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of all types of interventions, versus placebo, active monitoring, or other interventions, in any child with single or multiple infantile haemangiomas (IHs) located on the skin. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcome measures were clearance, a subjective measure of improvement, and adverse events. Secondary outcomes were other measures of resolution; proportion of parents or children who consider there is still a problem; aesthetic appearance; and requirement for surgical correction. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included 28 RCTs, with a total of 1728 participants, assessing 12 different interventions, including lasers, beta blockers (e.g. propranolol, timolol maleate), radiation therapy, and steroids. Comparators included placebo, an active monitoring approach, sham radiation, and interventions given alone or in combination.Studies were conducted in a number of countries, including China, Egypt, France, and Australia. Participant age ranged from 12 weeks to 13.4 years. Most studies (23/28) included a majority of females and different types of IHs. Duration of follow-up ranged from 7 days to 72 months.We considered most of the trials as at low risk of random sequence generation, attrition bias, and selective reporting bias. Domains such as allocation concealment and blinding were not clearly reported in general. We downgraded evidence for issues related to risk of bias and imprecision.We report results for the three most important comparisons, which we chose on the basis of current use. Outcome measurement of these comparisons was at 24 weeks' follow-up.Oral propranolol versus placeboCompared with placebo, oral propranolol 3 mg/kg/day probably improves clinician-assessed clearance (risk ratio (RR) 16.61, 95% confidence interval (CI) 4.22 to 65.34; 1 study; 156 children; moderate-quality evidence) and probably leads to a clinician-assessed reduction in mean haemangioma volume of 45.9% (95% CI 11.60 to 80.20; 1 study; 40 children; moderate-quality evidence). We found no evidence of a difference in terms of short- or long-term serious adverse events (RR 1.05, 95% CI 0.33 to 3.39; 3 studies; 509 children; low-quality evidence), nor in terms of bronchospasm, hypoglycaemia, or serious cardiovascular adverse events. The results relating to clearance and resolution for this comparison were based on one industry-sponsored study.Topical timolol maleate versus placeboThe chance of reduction of redness, as a measure of clinician-assessed resolution, may be improved with topical timolol maleate 0.5% gel applied twice daily when compared with placebo (RR 8.11, 95% CI 1.09 to 60.09; 1 study; 41 children;low-quality evidence). Regarding short- or long-term serious cardiovascular events, we found no instances of bradycardia (slower than normal heart rate) or hypotension in either group (1 study; 41 children; low-quality evidence). No other safety data were assessed, and clearance was not measured.Oral propranolol versus topical timolol maleateWhen topical timolol maleate (0.5% eye drops applied twice daily) was compared with oral propranolol (via a tablet taken once per day, at a 1.0 mg/kg dose), there was no evidence of a difference in haemangioma size (as a measure of resolution) when measured by the proportion of patients with a clinician-assessed reduction of 50% or greater (RR 1.13, 95% CI 0.64 to 1.97; 1 study; 26 participants; low-quality evidence). Although there were more short- or long-term general adverse effects (such as severe diarrhoea, lethargy, and loss of appetite) in the oral propranolol group, there was no evidence of a difference between groups (RR 7.00, 95% CI 0.40 to 123.35; 1 study; 26 participants; very low-quality evidence). This comparison did not measure clearance.None of our key comparisons evaluated, at any follow-up, a subjective measure of improvement assessed by the parent or child; proportion of parents or children who consider there is still a problem; or physician-, child-, or parent-assessed aesthetic appearance. AUTHORS' CONCLUSIONS We found there to be a limited evidence base for the treatment of infantile haemangiomas: a large number of interventions and outcomes have not been assessed in RCTs.Our key results indicate that in the management of IH in children, oral propranolol and topical timolol maleate are more beneficial than placebo in terms of clearance or other measures of resolution, or both, without an increase in harms. We found no evidence of a difference between oral propranolol and topical timolol maleate with regard to reducing haemangioma size, but we are uncertain if there is a difference in safety. Oral propranolol is currently the standard treatment for this condition, and our review has not found evidence to challenge this. However, these results are based on moderate- to very low-quality evidence.The included studies were limited by small sample sizes and risk of bias in some domains. Future trials should blind personnel and participants; describe trials thoroughly in publications; and recruit a sufficient number of children to deduce meaningful results. Future trials should assess patient-reported outcomes, as well as objective outcomes of benefit, and should report adverse events comprehensively. Propranolol and timolol maleate require further assessment in RCTs of all types of IH, including those considered problematic, as do other lesser-used interventions and new interventions. All treatments should be compared against propranolol and timolol maleate, as beta blockers are approved as standard care.
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Affiliation(s)
- Monica Novoa
- Hospital San Jose‐Fundacion Universitaria de Ciencias de la SaludPaediatric Dermatology DepartmentCarrera 19, No. 8A‐32BogotaColombia
| | - Eulalia Baselga
- Hospital de la Santa Creu i Sant PauPaediatric Dermatology DepartmentPare M Claret 167BarcelonaSpain08025
| | - Sandra Beltran
- Hospital San Jose‐Fundacion Universitaria de Ciencias de la SaludPaediatric Dermatology DepartmentCarrera 19, No. 8A‐32BogotaColombia
| | - Lucia Giraldo
- Hospital San Jose‐Fundacion Universitaria de Ciencias de la SaludPaediatric Dermatology DepartmentCarrera 19, No. 8A‐32BogotaColombia
| | - Ali Shahbaz
- University of AlbertaDepartment of Dermatology8‐112 Clinical Science BuildingEdmontonAlbertaCanadaT6G 2G3
| | - Hector Pardo‐Hernandez
- Iberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau) ‐ CIBER Epidemiología y Salud Pública (CIBERESP)C. Sant Antoni Maria Claret 171BarcelonaCatalunyaSpain08041
| | - Ingrid Arevalo‐Rodriguez
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoAv. Mariscal Sucre s/n y Av. Mariana de JesúsQuitoEcuador
- Hospital Ramon y Cajal (IRYCIS)Clinical Biostatistics UnitMadridSpain
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