Propranolol therapy for infantile haemangiomas: review of the literature

Update on Treatment of Infantile Hemangiomas: What’s New in the Last Five Years?

Among benign vascular tumors of infancy, hemangiomas are the commonest, affecting approximately 5–10% of one-year-old children. They are derived from a benign proliferation of vascular endothelial cells (VECs) in the mesoderm and may arise anywhere on the body around 1–2 weeks after birth. Infantile hemangiomas (IHs) are characterized by an early proliferative phase in the first year followed by a spontaneous progressive regression within the following 5 years or longer. IH prevalence is estimated to be 5%–10% in one-year-old children and commonly affects female, Caucasian and low-birth weight infants. Although most of them spontaneously regress, approximately 10% requires treatment to prevent complications due to the site of occurrence such as bleeding, ulceration, cosmetically disfigurement, functional impairment, or life-threatening complications. For over 30 years, steroids have represented the first-line treatment for IHs, but recently topical or systemic β-blockers are increasingly being used and recognized as effective and safe. A search for “Cutaneous infantile hemangioma” [All Fields] AND “Treatment” [All Fields] was performed by using PubMed and EMBASE databases. Treatment of IHs with labeled drugs, such as oral propranolol, but also with off-label drugs, such as topical β-blockers, including topical timolol and carteolol, steroids, itraconazole or sirolimus, with a focus on formulations types and adverse events were described in our review. We also discussed the benefits of pulsed dye laser and the treatment of IHs with involvement of central nervous system, namely the PHACE and LUMBAR syndrome.

Computational studies on binding, solvent, and pH effects on (S)-propranolol and methacrylic acid complex

Density functional theory methods have been applied to understand binding of (s)-propranolol, a template, to a methacrylic acid molecule acting as a functional monomer using basic 1:1 model. The model has been expanded to study the effect of various pH by adding hydronium and hydroxide ions solvated by water molecules to the template-monomer system, to mimic acidic and basic environments, respectively. This could be considered a model study towards a potential use of molecular imprinting method for the design of a transdermal patch for a topical and direct delivery of (s)-propranolol to hemangiomas. In addition, this study provides detailed binding site analysis of the template and functional monomer verified by the theoretical IR spectra analysis, as well as solvent and pH effects on template-monomer binding energy.

Propranolol for Treatment of Infantile Hemangioma: Efficacy and Effect on Pediatric Growth and Development

Purpose

Propranolol has been successful in treating problematic infantile hemangiomas (IH) but concerns regarding its effect on normal growth and development have been raised. This study examines physical growth, developmental milestones, and human growth hormone (hGH) levels in infants receiving propranolol for problematic IH.

Method

Monthly heights and weights of children undergoing propranolol therapy for IH were prospectively collected and tabulated. Data analysis and comparison to World Health Organization (WHO) weight-for-age and weight-to-length z-scores was performed. Questionnaires regarding milestones, efficacy, and guardian satisfaction were performed, and a combination of both chart results and phone conducted surveys was tabulated. Serum from a small representative cohort of age-matched children with IH treated and not treated with propranolol was collected.

Results

A total of 185 children receiving propranolol therapy between 2008 and 2013 for IH were assigned to this study. The children were divided into two cohorts based on the presence of comorbidities or risk factors that may affect growth and development (n = 142 no comorbidities, n = 43 with comorbidities). Neither cohort demonstrated deviation from normal weight in comparison to WHO normative data. There was a significant deviation for BMI-for-age and weight-for-age z-scores in our population, especially in patients on propranolol for more than 7 months. Based on data from participants, via either completed questionnaires or chart results, most children met their developmental milestones at or before target ages, regardless of the presence of comorbidities. Eighty percent of guardians noticed clinical improvement of the IH, with 91% either happy about or neutral to using the medication. hGH levels were higher in patients receiving propranolol therapy, but not significantly different.

Conclusion

Propranolol therapy is effective and well tolerated in the treatment of infantile hemangiomas. This study suggests that propranolol does not impair growth and has no impact on normal pediatric development.

Recurrence rate of infantile hemangioma after oral propranolol therapy

Oral propranolol is the treatment of choice for infantile hemangiomas. The growth relapse rate following oral propranolol therapy is not well established in the literature. The present study aimed at determining predictors of growth relapse of infantile hemangiomas after discontinuation of oral propranolol therapy. A retrospective analysis was performed of all cases of infantile hemangiomas aged ≤ 12 months undergoing oral propranolol therapy in a 6-year period. Of the 198 cases, regrowth after oral propranolol therapy was observed in 35 patients (18%). Facial hemangiomas showed a higher (p = 0.003) relapse rate as compared with other hemangiomas (27 out of 107 facial cases vs. 8 out of 91 with other location, respectively 25% and 8.8%). Of 35 growth relapses cases, 66% of cases (23 in total, 18 facial and 5 otherwise located hemangiomas) underwent a second cycle of oral propranolol therapy (median length of treatment 3 months, interquartile range 2-3). All cases had a successful outcome, either after a single cycle oral propranolol therapy (163 cases, 82%), or in case of regrowth, after a second therapy cycle (23 cases, 12%) or further conservative management (12 cases, 6%).Conclusion: Facial infantile hemangiomas relapse earlier and more frequently after oral propranolol therapy. We suggest to closely monitor these patients, as a second cycle of propranolol may be indicated. Prolonged oral propranolol therapy might be considered for facial infantile hemangiomas. What is Known: • Oral propranolol is the treatment of choice for infantile hemangiomas. • The growth relapse rate following oral propranolol is not well established. What is New: • The present study points out that facial infantile hemangioma relapse earlier and more frequently after oral propranolol therapy. • Patients with facial infantile hemangiomas should be monitored after propranolol therapy discontinuation.

Development of Lecithin/Chitosan Nanoparticles for Promoting Topical Delivery of Propranolol Hydrochloride: Design, Optimization and In-Vivo Evaluation

Propranolol (PPL) administered orally is considered as the first line drug for the treatment of infantile hemangioma, however several systemic adverse effects limit its use. For this reason, our work tackles the development and evaluation of PPL loaded chitosan nanoparticles (NPs), as an effective alternative for the treatment of infantile hemangioma. PPL -NPs were prepared using the double emulsion technique and the influence of the formulation variables on drug entrapment efficiency (EE), particle size (PS), percent released after 24 h (%R_24h) and zeta potential (ZP) were optimized using full factorial design. Two systems, namely F3 and F28 showing highest E.E., ZP and %R_24h with lowest PS, were fully characterized for DSC and TEM and incorporated into hydrogel with adequate viscosity. After ensuring safety for the selected nanoparticle, the hydrogel containing the optimized system was applied topically to rats. The in-vivo skin deposition in rats showed an accumulation of propranolol from the lecithin/chitosan nanocarrier by 1.56-1.91-fold when compared to the drug solution. The obtained result was further supported by the confocal laser scanning microscopy which showed fluorescence across the skin. PPL-HCL-loaded lecithin/chitosan nanoparticles could be considered as a potential candidate for treating infantile hemangiomas (IH) by maintaining therapeutic concentration topically while minimizing systemic side effects.

Propranolol for Surgeons in the Treatment of Infantile Hemangiomas

INTRODUCTION

Beta-blocker (Propanolol or Timolol maleate) treatment of infantile hemangiomas (IH) is a safe and effective treatment in the outpatient setting. The authors report a single surgeon's initial experience with setting up an outpatient service of beta-blocker treatment for head and neck IH at a tertiary children's hospital.

METHODS

A prospective study of children with head and neck IHs commenced in January 2015 with the end point being December 2018. Each child started either oral propranolol (2 mg/kg/day) or topical Timolol 0.5%.

RESULTS

Thirty-eight patients commenced a beta-blocker during the study duration. The mean age at time of starting therapy was 9 months (range 3 weeks to 116 months). Four patients were older than 12 months at commencement. The mean duration of treatment was 9 months. The response to treatment was excellent or complete in 29% (n = 11), good in 50% (n = 18) and mild in 10% (n = 4). The non response rate was 10% (n = 4). No major adverse effects occurred but 29% (n = 11) experienced minor side effects.

CONCLUSION

Low dose propranolol and topical Timolol is been safe and easy to use for surgeons who may not be regular prescribers or unfamiliar with treating children with IHs with beta-blocker therapy. In patient monitoring is unnecessary and parents can be taught easily to recognise side effects. Treating children from the start builds a trusting relationship with the family before the child requesting cosmetic revision of the fibro-fatty remnant.

Five years’ experience of combined intralesional therapy in infantile hemangioma

Background

Infantile hemangiomas (IHs) are common vascular tumors. Although it involutes spontaneously, outcomes are unpredictable. Intralesional therapy is one of its treatment modality. We present our experience with combined intralesional therapy for IHs over a 5-year duration. A total of 427 patients were treated and followed at Al-Azhar University Hospitals during the study period of 5 years. All patients were treated by intralesional therapy in the form of combined injection of triamcinolone and bleomycin. All patients were followed for the response. Response to the treatment was graded as marked, partial, and poor improvement.

Results

IHs were noticed within the first month of life in 90.2% of patients. The commonest site of involvement was head and neck in 90% of patients. The commonest clinical presentation was swelling with discoloration. Mean age was 7.43 ± 6.04 months and mean IHs size was 15.54 ± 11.13 cm2. The response to the treatment was highest for patients below 1 year of age. The reported complications were ulceration, scarring, and subcutaneous atrophy in some cases.

Conclusion

Combined intralesional therapy in IHs showed good efficacy in most patients. It is a reliable and safe treatment modality with clear curative effects and minimal complications. If IHs treatment is indicated, combined intralesional therapy should be considered as an alternative effective treatment modality.

Propranolol induces hemangioma endothelial cell apoptosis via a p53‑BAX mediated pathway

The use of propranolol for the treatment of infantile hemangioma (IH) has been widely investigated in recent years. However, the underlying therapeutic mechanism of propranolol for the treatment of IH remains poorly understood. The aim of the present study was to investigate the expression of proteins regulated by cellular tumor antigen p53 (p53) in associated apoptosis pathways in IH endothelial cells (HemECs) treated with propranolol. Furthermore, the present study aimed to investigate the exact apoptotic pathway underlying the therapeutic effect of propranolol against IH. In the present study, HemECs were subcultured and investigated using an inverted phase contrast microscope, immunocytochemical staining and a scanning electron microscope (SEM). Experimental groups and blank control groups were prepared. All groups were subjected to drug treatment. A high p53 expression model of HemECs was successfully established via transfection, and a low p53 expression model of HemECs was established using pifithrin-α. The apoptosis rate of each group was determined using Annexin V-fluorescein isothiocyanate/propidium iodide double staining and flow cytometry. The expression levels of downstream proteins regulated by p53 [tumour necrosis factor receptor superfamily member 6 (FAS), p53-induced death domain-containing protein (PIDD), death receptor 5 (DR5), BH3-interacting domain death agonist (BID), apoptosis regulator BAX (BAX), p53 unregulated modulator of apoptosis (PUMA), phosphatidylinositol-glycan biosynthesis class S protein (PIGS), and insulin-like growth factor-binding protein 3 (IGF-BP3)] were revealed in the experimental and control groups via western blotting. Microscopic observation revealed the growth of an adherent monolayer of cells, which were closely packed and exhibited contact inhibition. Immunocytochemical staining demonstrated increased expression of clotting factor VIII. SEM analysis revealed presence of Weibel-Palade bodies. The results of the analyses verified that the cultured cells were HemECs. The staining of the samples resulted in a significantly increased rate of apoptosis in experimental groups compared with the blank control group. This result suggested that there is an association between p53 expression and the rate of apoptosis of propranolol-treated HemECs. The results of the western blot analysis demonstrated an upregulation of BAX expression and a downregulation of IGF-BP3 expression in the HemECs treated with propranolol. There were no significant differences in the expression levels of FAS, DR5, PIDD, BID, PUMA and PIGS between experimental and control groups. This result suggests that p53 has an important role in HemEC apoptosis. The results of the present study additionally suggest that the propranolol-induced HemEC apoptosis pathway is a mitochondrial apoptosis pathway and is regulated by p53-BAX signaling.

Interventions for infantile haemangiomas of the skin

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.

Spectral Doppler ultrasound for predicting long-term response to topical timolol in children with infantile hemangioma

BACKGROUND

To assess the utility of color and spectral Doppler ultrasound at predicting infantile hemangioma (IH) response to timolol.

METHODS

Eighty-three children (0-6 months old) with IH were treated with topical 0.5% timolol maleate twice daily for 6 months. They underwent color and spectral Doppler sonographic examinations at the first visit and 1 month after beginning timolol. Hemangioma volume, arterial diameter (AD), venous diameter (VD), resistance index (RI), pulsatility index (PI), peak arterial systolic velocity (PASV), maximum venous velocity, and mean venous velocity were measured. Therapeutic outcome was assessed at 6 months.

RESULTS

The hemangiomas were classified as deep (55.4%), hybrid (28.9%), or superficial (15.7%) and were located in the head and neck (36.1%), limbs (21.7%), or torso (42.2%). Regression occurred in 53 patients (63.9%). Timolol was the most effective in patients aged 5-6 months, in superficial hemangiomas, and in hemangiomas located on the torso. Receiver operating characteristic analysis revealed that changes in RI (sensitivity/specificity: 71.7%/96.7%), PI (sensitivity/specificity: 73.6%/86.7%), PASV (sensitivity/specificity: 81.1%/80.0%), change in arterial diameter (sensitivity/specificity: 58.5%/83.3%), and change in venous diameter (sensitivity/specificity: 62.3%/73.3%) at 1 month could predict response to timolol at 6 months.

CONCLUSIONS

Changes in AD, VD, RI, PI, and PASV at 1 month could be used to predict response to timolol at 6 months. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:480-487, 2017.

Vascular Anomalies: A Pediatric Surgeon's Perspective

Anomalies affecting the capillary and venous channels form the bulk of the spectrum of vascular anomalies. As per International Society for the Study of Vascular Anomalies (ISSVA) classification, these are referred to as hemangiomas and venous malformations respectively. The present article is a descriptive note of their management and outcomes. Retrospective records of patients over 17 y (January 2000 through December 2016) were reviewed for presentation, management and outcomes. Outcomes were graded into 3 subgroups based on subjective assessment of clinical images: Group A = near-total response (>90%); Group B = 50-90% and Group C = <50% reduction. Among 90 cases of hemangioma, majority were located in head and neck (86.7%). Outcomes recorded in children who received steroids (n = 36) were: Group A = 61.1%, B = 25% and C = 13.9%; steroids and beta-blockers (n = 8): Group A = 62.5%, B = 25% and C = 12.5%; only beta-blockers (n = 4): Group A = 75% and B = 25%; intralesional sclerotherapy (n = 32): Group A = 55.2% and B = 44.8%; steroids followed by sclerotherapy (n = 7): Group A = 28.6% and B = 71.4%; excision (n = 3): Group A = 100%. Among 171 cases of venous malformation, majority were located in head and neck (49.6%). Outcomes recorded in children who received sclerotherapy (n = 165) were Group A = 20.7%, B = 51% and C = 28.3%; steroids (n = 3): Group A = 100%; beta-blockers (n = 1): Group C = 100%; excision (n = 2): Group A = 100%. Better outcome was noted in smaller-sized lesions and those who required lesser volume of sodium tetradecyl sulfate (STS) injection. Thus, to conclude, the decision regarding the choice and timing of each therapeutic modality should be individualized based on location, size and type of the lesion. The goal of management in these lesions should be to improve the quality of life rather than elimination of the lesion.

Comparison of Efficacy and Safety Between Propranolol and Steroid for Infantile Hemangioma: A Randomized Clinical Trial

Importance

There are limited data from randomized clinical trials comparing propranolol and steroid medication for treatment of infantile hemangioma (IH).

Objective

To determine the efficacy and safety of propranolol compared with steroid as a first-line treatment for IH.

Design, Setting, and Participants

This randomized clinical noninferiority trial tested the efficacy and safety of propranolol vs steroid treatment for IH at a single academic hospital. All participants were diagnosed with IH between June 2013 and October 2014, had normal heart function, and had not been previously treated for IH.

Interventions

The participants were randomly assigned to either the propranolol group or the steroid group. In the propranolol group, the patients were admitted, observed for adverse effects for 3 days after treatment initiation, and then released and treated as outpatients for 16 weeks (2 mg/kg/d). In the steroid group, the patients were seen as outpatients from the beginning and were also treated for 16 weeks (2 mg/kg/d).

Main Outcomes and Measures

The primary efficacy variable was the response to treatment at 16 weeks, which was evaluated by the hemangioma volume using magnetic resonance imaging before and at 16 weeks after treatment initiation. While comparing the effect of medication between the groups, we monitored the adverse effects of both drugs.

Results

A total of 34 patients (15 boys, 19 girls; mean age, 3.3 months; range, 0.3-8.2 months) were randomized to receive either propranolol or steroid treatment (17 in each treatment group). Guardians for 2 patients in the steroid group withdrew their consent, and 1 patient in the propranolol group did not complete the efficacy test. The intention-to-treat analysis, applying multiple imputations, found the treatment response rate in the propranolol group to be 95.65%, and that of the steroid group was 91.94%. Because the difference in response rate between the groups was 3.71%, propranolol was considered noninferior. We found that there was no difference between the groups in safety outcomes.

Conclusions and Relevance

Our trial demonstrated that propranolol was not inferior to steroid with respect to therapeutic effects in IH.

Trial Registration

clinicaltrials.gov Identifier: NCT01908972.

Circulating Levels of Vascular Endothelial Growth Factor and Basic Fibroblastic Growth Factor in Infantile Hemangioma Versus Vascular Malformations

Few preliminary reports studied the utility of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) for differentiation between infantile hemangiomas (IHs) and vascular malformations. The aim of this study was to investigate the role of serum VEGF and bFGF levels in differentiating IHs from vascular malformations and identifying the stage and clinical course of IHs. Serum levels of VEGF and bFGF were assessed in 60 infants and children with various cutaneous vascular anomalies defined in 3 groups: proliferating IHs (n = 25), involuting IHs (n = 23), and vascular malformations (n = 12), in comparison with their levels in 40 healthy matched control. Serum levels of VEGF and bFGF were significantly elevated in all groups as compared to control ( P < .001, respectively). Both proliferating and involuting IHs had comparable levels of both markers ( P > .05, respectively) that were significantly higher in comparison with vascular malformations ( P < .05, respectively). Significantly lower VEGF levels were found in IHs that had regressed spontaneously (n = 11) compared to those regressed by treatment (n = 37), ( P < .05); meanwhile, bFGF showed no significant difference between both groups ( P > .05). Using receiver operating characteristic curves, a combined use of VGEF and bFGF yielded a sensitivity of 85.42% and a specificity of 100% for differentiating IHs from vascular malformations. Serum VEGF and/or bFGF levels are increased in cutaneous vascular anomalies and can differentiate IHs from vascular malformations. None of these markers could help in identifying the stage of IHs. Low VEGF is associated with spontaneous regression of IHs.

The impact of cardiovascular drugs on the efficacy of local anesthesia in dentistry

BACKGROUND AND AIM

Drugs used chronically by patients with diseases of the cardiovascular system (group C of the ATC classification) may act on adrenergic receptors and/or certain ion channels, which gives them the potential to interact with the action of local dental anesthetics. The aim of the study was to investigate the effect of systemically administered chronic cardiovascular medication (oral route) on the efficacy of intraoral local anesthesia in patients with diseases of the cardiovascular system.

PATIENTS AND METHODS

This was a prospective cohort study which analyzed the efficacy of local terminal anesthesia (onset of anesthesia, duration anesthetized area) in the upper jaw of 70 patients: 40 patients on medication for cardiovascular system disorders and 30 patients who were not using these drugs (the control group). The following cardiovascular drugs were used: beta blockers, angiotensin converting enzyme inhibitors, calcium channel blockers, vasodilatators, diuretics, angiotensin receptor blockers, antiarrhythmics, statins and alfa blockers.

RESULTS

The onset of anesthesia on the vestibular side was faster in those taking cardiovascular drugs (40.50±19.87 s) than the control patients (58.93±31.07 s; P = 0.004) and duration of anesthesia on this side was shorter. Although the difference was not significant, it was evident that on vestibular and palatal side the anesthetized area was more rapidly reduced in the patients taking cardiovascular drugs. The duration of cardiovascular therapy also had a significant impact on the anesthetized area.

CONCLUSION

Drugs acting on cardiovascular system may influence the effect of local anesthetics used in dentistry, possibly through interaction with autonomic receptors and ion channels.

Response to propranolol in infantile hemangioma

Propranolol, 2 mg/kg/day, is effective in the treatment of infantile hemangioma. We report the response to propranolol in infants with hemangioma at a dose of 1 mg/kg/day. Sixteen infants with newly diagnosed infantile hemangioma were given propranolol at a dose titrated from 0.5 mg/kg/day then increased to 1 or 2 mg/kg/day based on response to treatment until the lesions showed clinical stability for 3 consecutive months. Five out of 16 patients (31.2%) responded to propranolol at 1 mg/kg/day, while the remainder required 2 mg/kg/day for response. Vascular endothelial growth factor significantly decreased after treatment (median, 117.8 pg/mL; range, 35.3-468.7 pg/mL vs 59.2 pg/mL; range, 26.3-133.0 pg/mL; P = 0.016). Therefore, we recommend initiating treatment at 0.5 mg/kg/day for 2 days, then 1 mg/kg/day for 1 month. If the hemangioma has not decreased in size by 1 month follow up, the dose is subsequently increased to 2 mg/kg/day.

Evidence-Based Medicine in the Treatment of Infantile Hemangiomas

Over the past decade, the treatment of infantile hemangiomas has undergone dramatic breakthroughs. This review critically evaluates the latest literature that supports the myriad treatment options for infantile hemangiomas. It chronicles the fading role of steroid therapy and evolution of propranolol use as the major treatment modality. Although propranolol is helping this disease become more of a medical disease and less of a surgical dilemma, the report also reveals a continued search to find nonsystemic treatment options. In summary, this is an evidence-based medicine review for the treatment of infantile hemangiomas.

Infantile Hemangiomas: Pathogenesis and Review of Propranolol Use

BACKGROUND

Infantile hemangiomas are complex benign vascular tumors that present after birth. Hemangioma lesions have a predictable course of growth, but little is understood about the mechanism behind their development. Infantile hemangiomas are considered proliferative lesions of the endothelial cells.

PURPOSE

To effectively manage infants with infantile hemangiomas, a clear understanding of the pathogenic pathways is important and can assist the healthcare provider with effective treatment. This understanding will facilitate a relationship of support with the families of affected infants.

METHODS/SEARCH STRATEGIES

EBSCO host and Ovid database search for key words of infantile hemangiomas, propranolol, vascular lesion, and proliferative lesion was utilized. Articles on pathophysiology along with recent research studies were include in the search.

FINDINGS/RESULTS

The use of propranolol is a recent development in the treatment of infantile hemangiomas, which has shown a high rate of response in decreasing the size and reducing the potential for life-long complications. Different studies have shown the same success rate with the use of propranolol but with different variables.

IMPLICATIONS FOR PRACTICE

As a healthcare team member, better identification and customized care of these patients can reduce the rare but devastating complications of infantile hemangiomas.

IMPLICATIONS FOR RESEARCH

Future research can help identify the most effective dose and course of propranolol administration.

Clonidine as an adjuvant for propranolol enhances its effect on infiltrative cutaneous analgesia in rats

Clonidine prolongs duration of analgesia when used as an adjunct to local anesthetics for infiltrative cutaneous analgesia, and propranolol produces local anesthesia. The purpose of the experiment was to evaluate clonidine as an adjuvant for propranolol on the quality and duration of cutaneous analgesia. A rat model of cutaneous trunci muscle reflex (CTMR) in response to local skin pinprick was employed to evaluate the cutaneous analgesic effect of propranolol combined with clonidine. The long-lasting local anesthetic bupivacaine was used as control. Cutaneous analgesia elicited by propranolol and bupivacaine was dose-dependent, and both propranolol (9.0μmol) and bupivacaine (1.8μmol) produced 100% nociceptive blockade. On an 50% effective dose (ED50) basis, the relative potency was bupivacaine [0.48 (0.42-0.55) μmol] greater than propranolol [2.27 (1.98-2.54) μmol] (p<0.01). Subcutaneous saline and clonidine (0.12μmol) did not produce cutaneous analgesia. The mixture of an ineffective-dose clonidine (0.12μmol) and a drug (propranolol or bupivacaine) at ED50 or ED95 increased the potency and extended the duration at producing cutaneous analgesia. The resulting data demonstrated that propranolol is less potent than bupivacaine as an infiltrative anesthetic. Clonidine as an adjuvant for propranolol or bupivacaine has a significant peripheral action in increasing the depth and duration of action on infiltrative cutaneous analgesia.

Tooth extraction from a patient with cavernous hemangioma in maxillofacial region: case report

Hemangiomas are benign vascular tumors which represent a rapid growth pattern followed by the involution phase. Generally, they are located in the soft tissues and are usually diagnosed in the first decade of life. Hemangiomas are mostly asymptomatic and rarely affect jaw bones. Mandible is affected more often than maxilla. If there is no complication present, treatment may not be necessary. Treatment planning of hemangiomas should be done by considering the location and the size of the lesion as well as the proximity to vital anatomical structures. The aim of this case report is to describe the procedures of tooth extraction in a patient who had been diagnosed as having maxillary cavernous hemangioma.

Propranolol: Effectiveness and Failure in Infantile Cutaneous Hemangiomas

Infantile hemangiomas (IHs) occur in early infancy and are considered to be one of the most frequent childhood tumors. Poor responsiveness to the treatment and complications are reported in about 10 % of patients. For years, the most common treatments for cutaneous and complicated IHs were corticosteroids, interferon-α, vincristine, laser therapy, or surgical intervention. More recently, treatment with propranolol has been reported with high success rates, both in the cutaneous and complicated form of IHs, and it is now considered to be the first-line treatment for IHs. Herein we report five cases of cutaneous IHs who presented at our unit between January 2011 and June 2012: in three of five patients, the lesion improved soon after the beginning of propranolol treatment; one case presented slow but complete resolution; and in one patient the treatment was unsuccessful. Patients who do not respond to propranolol have been seldom reported in the literature. However, the failure of propranolol treatment in childhood hemangiomas has been more frequent in our experience than that reported in previous case series. More attention should be given to the cases that poorly or negatively respond to treatment, and to the mechanisms underlying the failure to respond to treatment with propranolol.

Propranolol combined with dopamine has a synergistic action in intensifying and prolonging cutaneous analgesia in rats

BACKGROUND

The purpose of the experiment was to assess interactions of dopamine with propranolol as an infiltrative anesthetic.

METHODS

After injecting the rats with four doses of drugs subcutaneously, the cutaneous analgesic effect of propranolol was compared with dopamine through the blockade of cutaneous trunci muscle reflex (CTMR) in response to local skin pinprick. Drug-drug interactions were examined via an isobolographic analysis.

RESULTS

We demonstrated that the action of propranolol and dopamine was dose dependent to skin infiltrative analgesia. On the ED(50) (50% effective dose) basis, the rank of drug potency was propranolol (11.3 [10.6-12.2]μmol) > dopamine (195 [188-205]μmol) (p < 0.001). At the equi-anesthetic doses (ED(25), ED(50), ED(75)), the block duration caused by dopamine was equal to that caused by propranolol. Coadministration of dopamine and propranolol exhibited a synergistic effect on infiltrative cutaneous analgesia.

CONCLUSIONS

The preclinical data showed that dopamine produced a lesser potency but a comparable duration of cutaneous analgesia compared to propranolol. Adding dopamine to propranolol potentiated and prolonged propranolol's cutaneous analgesic effect.

Treatment with propranolol for infantile hemangiomas: A case series of 106 infants

The aim of the present study was to investigate the clinical benefit and side effects of propranolol treatment in 106 children with infantile hemangiomas (IHs). A retrospective chart review was conducted on all children who attended the clinic between September 16, 2009 and November 11, 2013. Propranolol was administered in a progressive schedule reaching 1.0-1.5 mg/kg/day, divided into three doses. Demographic data, clinical features, imaging, treatment regimens and outcomes were investigated. Any adverse effects following medication were evaluated and managed accordingly. Preliminary analysis of the data showed the inclusion of 106 children (71 female and 35 male) with a mean age and weight at onset of treatment of 5.1 months and 7.3 kg, respectively. All 106 patients responded positively to treatment. Side effects that required intervention and/or close monitoring included diarrhea (n=10), hypotension (n=7), nightmares (n=2), agitation (n=1) and cold extremities (n=1). No long-term adverse effects were observed in any of the patients. In conclusion, propranolol administered orally at 1.0-1.5 mg/kg/day had a rapid therapeutic effect for resolving IHs with few complications.

Negative pressure wound therapy in the treatment of ulcerated infantile haemangioma

BACKGROUND

Infantile haemangioma is a common benign tumour of infancy. Ulceration is the most common complication and is often painful and difficult to treat. Propranolol therapy is widely used to induce involution in rapidly growing or ulcerated lesions, or those in anatomically awkward locations. The ideal dressing regimen for these lesions would provide effective analgesia, act as a wound dressing, and aid involution of the primary lesion. To date, no ideal regimen has been established. Negative pressure wound therapy (NPWT) has been used in adult and paediatric populations to help improve wound healing in a variety of settings. It may provide a useful alternative to traditional dressing regimens in ulcerated infantile haemangioma.

METHODS

Six consecutive patients with ulcerating infantile haemangioma presenting to the Royal Children's Hospital vascular anomalies clinic were included in the study. Each patient was treated with a combination of NPWT and propranolol. Outcomes including time to wound healing, perceived ease of dressing management, and analgesia were recorded.

RESULTS

Complete wound healing was obtained in all cases. Patient outcomes in terms of analgesia, comfort, and ease of wound dressing were improved following application of NPWT.

DISCUSSION/CONCLUSIONS

We propose that this regimen represents a novel therapy for management of ulcerated infantile haemangioma. Possible mechanisms for healing effect, and improved analgesia are discussed. Further investigation is required to determine if negative pressure wound therapy results in faster healing times compared to traditional dressing regimens.

Topical timolol maleate for superficial infantile hemangiomas: an observational study

PURPOSE

The objective of this study was to assess the clinical effects and safety of topical timolol maleate for the management of superficial infantile hemangiomas (IHs).

MATERIALS AND METHODS

From October 2012 to March 2014, 35 infants (24 girls and 11 boys; 2 to 10 months old; median age, 4.7 months) with superficial hemangiomas were treated with the local application of timolol maleate in the authors' department. Thirty-five lesions were treated using topically administrated timolol maleate every 12 hours for a mean duration of 22 weeks (range, 6 to 45 weeks). Follow-up visits were scheduled monthly and changes in tumor size, texture, and color were recorded. Treatment response was scored according to a 3-point scale system as good, partial, or no response. Adverse effects after medication were evaluated and managed accordingly.

RESULTS

All patients completed treatment. Of the 35 hemangiomas, 18 (51.4%) showed a good response, 10 (31.4%) showed a partial response, and 6 (17.2%) had no response. The total response rate was 82.8% (29 of 35). Clinically, no systemic or local side effects caused by timolol maleate were observed in the patients.

CONCLUSIONS

Topical timolol maleate could provide an effective and safe alternative to the systemic use of propranolol for the treatment of superficial IHs. Further prospective studies are needed to confirm the efficacy and safety of topical timolol maleate for the treatment of IHs.

Extracranial vascular malformations (hemangiomas and vascular malformations) in children and adolescents - diagnosis, clinic, and therapy

The field of extracranial vascular anomalies is considered as special focus of pediatric otolaryngology and it has shown a rapid development during the last years. The reason for this interest is finally also due to the global acceptance of the classification introduced by the ISSVA (International Society for the Study of Vascular Anomalies). Hemangiomas are the most frequently observed vascular tumors. Today the systemic propranolol therapy is mostly used for therapy of hemangiomas requiring treatment. Increasingly, the topical application of beta blocker is discussed while the benefit in the head and neck seems to be limited. Vascular malformations are classified according to the morphology of the affected part of the vascular system in arterial, venous, arterio-venous, lymphatic, capillary, and combined vascular malformations. Conventional surgery, sclerosing therapy, and laser treatment are invasive options for the treatment of lymphatic malformations. The options for the treatment of venous malformations could be significantly improved during the last years. In this context, the use of Nd:YAG laser, the conservative treatment of the localized disseminated intravascular coagulation with low-molecular weight heparin, the re-discovery of bleomycin as effective sclerosing agent, and the improvement of alcohol-based embolization agents must be mentioned. Today the treatment with dye laser is the preferred therapy for capillary malformations and it is superior to other therapeutic options as for example photodynamic therapy. Arterio-venous malformations as representatives for high-flow lesions are the high-risk lesions. Frequently they are compared to malignant head and neck tumors, in particular when a curative treatment can no longer be assured because of diffuse or multifocal extent and when the disease shows a progressive course. The combined treatment of embolization and surgical resection and if necessary consecutive defect reconstruction have turned out to be appropriate for arterio-venous malformations. Incurable findings are still a major challenge. Despite the introduction of antiangiogenetic drugs in oncology, the medicamentous therapeutic approach could not be established for arterio-venous malformations up to now.

Cavernous hemangioma of tongue: management of two cases

Hemangiomas are benign tumours of infancy and childhood, most commonly located in the head and neck region and occur more frequently in the lips, tongue and palate. The treatment depends upon lesion location, size and evolution stage and the patient's age. This paper describes the management of cavernous hemangioma in a 2 -year -old child and 14 -year -old child using different approaches.

Intra-thyroidal hemangioma--a rare congenital anomaly: case presentation and literature review

Infantile hemangiomas (IH) present and evolve in a predictable way. In certain cases, however, they can be of clinical significance. IHs in the airway can cause significant respiratory distress. We present the first reported case of an intrathyroidal hemangioma to cause significant respiratory distress, which was successfully treated with propranolol and dexamethasone. A review of the literature was also performed.

Propranolol promotes accelerated and dysregulated adipogenesis in hemangioma stem cells

BACKGROUND

Infantile hemangiomas (IHs) are the most common tumor of infancy, yet there are no Food and Drug Administration-approved therapeutics to date. Recently, the nonselective β-adrenergic-blocker propranolol has been shown to be a safe and effective means of treating IHs, although its mechanism has yet to be elucidated. We have previously demonstrated that propranolol induces early and incomplete adipogenesis in stem cells derived from hemangiomas. We hypothesize that propranolol promotes dysregulated adipogenesis via the improper regulation of adipogenic genes.

METHODS

Hemangioma stem cells (HemSCs) isolated from resected IH specimens were treated with adipogenic medium for 1 or 4 days in either propranolol or vehicle. Cell death was measured by the incorporation of annexin V and propidium iodide by flow cytometry. Adipogenesis was assessed by visualizing lipid droplet formation by Oil Red O staining. Proadipogenic genes C/EBPα, C/EBPβ, C/EBPδ, PPARδ, PPARγ, RXRα, and RXRγ were analyzed by quantitative reverse transcription and polymerase chain reaction.

RESULTS

Hemangioma stem cells treated with propranolol increased lipid droplet formation compared to vehicle-treated cells indicating increased adipogenesis. Cell death as measured by FACS analysis indicated that the propranolol-treated cells died due to necrosis and not apoptosis. During adipogenesis, transcript levels of PPARδ, PPARγ, C/EBPβ, and C/EBPδ were significantly increased (P<0.01) in propranolol-treated cells relative to control cells. In contrast, RXRα and RXRγ levels were significantly decreased (P<0.05), and C/EBPα, a gene required for terminal adipocyte differentiation, was strongly suppressed by propranolol when compared to vehicle-treated cells (P<0.01).

CONCLUSIONS

In HemSCs, propranolol accelerated dysregulated adipogenic differentiation characterized by improper adipogenic gene expression. Consistent with accelerated adipogenesis, propranolol significantly increased the expression of the proadipogenic genes, PPARγ, C/EBPβ, and C/EBPγ compared to control. However, propranolol treatment also led to improper induction of PPARδ and suppression of C/EBPα, RXRα, and RXRγ. Taken together these data indicate that propranolol promoted dysregulated adipogenesis and inhibited the HemSCs from becoming functional adipocytes, ultimately resulting in cell death. Understanding this mechanism behind propranolol's effectiveness will be a vital factor in producing more effective therapies in the future.

Increased apoptosis and secretion of tryptase by mast cells in infantile haemangioma treated with propranolol

Propranolol is increasingly used to treat problematic infantile haemangioma (IH), although its molecular mechanisms remain unclear. A key feature of propranolol therapy is the decreased deposition of fibrofatty residuum compared with spontaneously involuting IH. This study investigated the molecular consequences of propranolol treatment for IH in vivo.Immunohistochemical and terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) staining was performed on five age matched patients with proliferative IH. Two patients (A and B) were undergoing propranolol treatment at the time of surgical resection.Propranolol treatment increased apoptosis, and induced mast cells to degranulate and secrete tryptase into the interstitium. The microvessels of patient A were immature [weak von Willibrand Factor (vWF), and strong osteoprotegerin (OPG) staining], comparable to untreated proliferative IH, while those of patient B were mature (strong vWF staining, and no OPG staining). The perivascular CD90 mesenchymal stem cell population was preserved in both propranolol treated patients.Using rarely obtained biopsies from IH patients treated with propranolol, we show increased apoptosis by propranolol for the first time in vivo. We also suggest that mast cells, through secreted proteases, may contribute to the decreased fibrofatty residuum seen with propranolol treatment.

Management of infantile hemangiomas: current trends

Infantile hemangiomas (IH) are common vascular tumours. IH have a characteristic natural course. They proliferate rapidly during the early infantile period followed by a period of gradual regression over several years. Most of the uncomplicated IH undergo spontaneous involution, with a small proportion of cases requiring intervention. These are children with IH in life-threatening locations, local complications like haemorrhage, ulceration and necrosis and functional or cosmetic disfigurements. Systemic corticosteroids have been the first line of treatment for many years. Recently, non-selective beta-blockers, such as oral propranalol and topical timolol, have emerged as promising and safer therapies. Other treatment options include interferon α and vincristine which are reserved for life-threatening haemangiomas that are unresponsive to conventional therapy. This review mainly focuses on the current trends and evidence-based approach in the management of IH.

The role of propranolol in the treatment of infantile hemangioma

INTRODUCTION

Infantile hemangioma (IH) is one of the most common childhood tumors. There are various medical or surgical therapeutic options, all with suboptimal results. Recently, the successful use of propranolol for involution of IH was described. We report the results of a single-center experience with this therapeutic option.

OBJECTIVE

To prospectively assess the efficacy and safety of propranolol in children with infantile hemangioma.

METHODS

We performed a prospective analysis of clinical data of all patients with IH referred to a pediatric cardiology center for baseline cardiovascular assessment prior to propranolol therapy. Propranolol was given at a starting dose of 1 mg/kg/day and titrated to a target dose of 2-3 mg/kg/day according to clinical response. Efficacy was assessed through a photograph-based severity scoring scale. Safety was assessed by collecting data regarding significant side effects.

RESULTS

Starting in 2010, 30 patients (15 female) were referred for propranolol treatment of IH, at a median age of six months (1-63 months). The mean target propranolol dose was 2.8 mg/kg/day, with a mean duration of therapy of 12 months. All patients experienced significant reduction of IH size and volume. There were no side effects.

CONCLUSIONS

In our experience propranolol appears to be a useful and safe treatment option for severe or complicated IH, achieving a rapid and significant reduction in their size. No adverse effects were observed, although until larger clinical trials are completed, potential adverse events should be borne in mind and consultation with local specialists is recommended prior to initiating treatment.

Propranolol treatment of complicated hemangiomas

OBJECTIVES

To evaluate laboratory and radiological features of hemangiomas in childhood in addition to efficacy and safety of propranolol as a first-line treatment of complicated hemangiomas retrospectively.

METHODS

The files of 60 patients who were diagnosed as capillary hemangioma were evaluated retrospectively. Fourteen children with complicated hemangiomas treated with propranolol were analysed, in terms of side effects, efficacy and duration of treatment.

RESULTS

These fourteen patients (23 %) were treated with propranolol because of ulcerated, infected and/or deep seated localisations. The duration of treatment with propranolol were between 3 and 12 mo (median: 6 mo). Bronchospasm was observed in one patient during treatment. Except for two patients, all of them responded to propranolol treatment with limited side effects.

CONCLUSIONS

The present results support that propranolol is safe and effective treatment choice for complicated infantile hemangiomas, because of minimal side effects and encouraging response rates (80 %). In addition, the authors suggest that routine cranial radiological imagings might not be necessary for hemangiomas without any neurological symptoms.

Benign mass in tonsil- cavernous hemangioma

Cavernous hemangioma is also called as 'ANGIOMA CAVERNOSUM' or 'CAVERNOMA' as benign lesion of blood vessels. They are similar to strawberry hemangioma but deeply situated. Although most often associated with skin it is also sometimes found in mucous membrane, brain and the viscera. The diagnosis of hemangiomas is mainly based on clinical evaluation . Isolated hemangiomas in the tonsillar tissue is a rare occurance. In this we report had a case of adult tonsillar hemangioma of left side associated with recurrent tonsillitis . He was effectively managed surgically without any complications.

Propranolol in a case series of 174 patients with complicated infantile haemangioma: indications, safety and future directions

BACKGROUND

Infantile haemangioma (IH) is a benign, common and self-limiting tumour of infancy; only a minority of cases need active treatment. Currently, propranolol appears superior to classic treatments.

OBJECTIVES

To document in a prospective study indications and side-effects of propranolol for complicated IH in a large patient group.

METHODS

Analysis of prospectively collected data was performed on 174 patients with IH treated with propranolol in a tertiary referral centre from September 2008 to January 2012.

RESULTS

The group consisted of children with a potentially threatening and/or complicated IH; the girl/boy ratio was 123/51, and the mean age at the start of treatment was 4·8 months. In 173 cases (99·4%), treatment was successful, as assessed nonquantitatively by clinical observation. This striking effect was characterized by immediate cessation of growth, softening, fading of the erythema and rapid induction of regression. The mean duration of treatment was 10·7 months. The most important adverse effects were hypotension (3·4%), wheezing (9·2%), nocturnal restlessness (22·4%) and cold extremities (36·2%). In one patient, propranolol was stopped. In 15 patients it was necessary to reduce the dose, although the lower dose was still effective.

CONCLUSIONS

In this study, propranolol was effective and safe in almost all patients with complex IH. Administration of systemic medication to an infant with a benign condition requires careful consideration, as only a minority of patients with IH require an active medical intervention. A shift of the indication of propranolol for IH is evident, expanding its application for life-threatening situations or severe functional impairment to early prevention of disfigurement or cosmetically permanent sequelae. However, the indication for such an active approach should be determined by experienced physicians.