Dramatic response to topical timolol lotion of a large hemifacial infantile haemangioma associated with PHACE syndrome

Application of topical betaxolol to cure superficial infantile hemangioma: A pilot study

BACKGROUND

Beta-blockers have gradually become an attractive option for the treatment of infantile hemangiomas. Topical application is preferred to oral administration because of their potential systemic adverse effects. The aim of this study is to investigate the effect of betaxolol in treating superficial infantile hemangioma.

METHODS

Seventy-four infants admitted to the First Affiliated Hospital of Xinjiang Medical University from 2018 to 2019 were observed and recorded. Variables such as color, size, tension, and thickness were recorded monthly and evaluated using visual analog scales. Multi-factor analysis of variance with repeated measurements and the non-parametric Kruskal-Wallis H test were used to compare clinical effectiveness across the different groups.

RESULTS

After 6 months of treatment, 33.78% (25/74) showed excellent results, 55.41% (41/74) had good responses, 8.11% (6/74) had moderate responses, and 2.70% (2/74) had poor responses. Local discomfort and systemic complications were not found. There was no significant difference in gender and location of occurrence among groups (p > 0.05), and the effect of topical application of betaxolol was optimum in the children aged 0-3 months (p = 0.002). None of three age groups had statistically significant difference in heart rate and blood pressure after accepting treatment (1 month, p = 0.618; 4 months, p = 0.138; 6 months, p = 0.757).

CONCLUSIONS

Our study showed that topical administration of betaxolol was effective and well tolerated for superficial infantile hemangiomas, particularly in the early proliferative stage. However, its safety and efficacy need further research.

Repurposing Ophthalmologic Timolol for Dermatologic Use: Caveats and Historical Review of Adverse Events

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.

[Mechanisms of adrenergic β-antagonist for wounds and its application prospect in diabetic foot ulcers]

Objective

To review the research progress of adrenergic β-antagonists on wounds and diabetic chronic cutaneous ulcers healing in recent years, and to investigate its application prospect in diabetic foot ulcer (DFU).

Methods

The latest literature about the role of adrenergic β-antagonists in wounds and diabetic chronic cutaneous ulcers healing was extensively reviewed, and the mechanisms of adrenergic β-antagonists for wounds and its potential benefit for DFU were analyzed thoroughly.

Results

The adrenergic β-antagonists can accelerate the wound healing. The possible mechanisms include accelerating re-epithelialization, promoting angiogenesis, improving neuropathy, and regulating inflammation and growth factors, etc. At present clinical research data showed that the adrenergic β-antagonists may be an adjuvant treatment for diabetic chronic cutaneous ulcers.

Conclusion

Adrenergic β-antagonists maybe promote the healing of wounds and diabetic chronic cutaneous ulcers. However, more long-term follow-up and high-quality randomized control studies are needed to further verify their efficacy and safety for DFU.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence‐based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence‐based guidelines for the management of vascular anomalies.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Effect of topical timolol on response rate and adverse events in infantile hemangioma: a meta-analysis

A number of clinical trials evaluated the effect of topical timolol in the treatment of infantile hemangioma and provided inconsistent results. The present study assessed the response rate and adverse events of topical timolol in the treatment of infantile hemangioma. Pubmed, Embase, China National Knowledge Infrastructure (CNKI), Wanfang, and Cochrane library were searched until October 2016. Specific inclusion criteria were used to evaluate articles. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. The meta-analysis was performed using a random effect model. A total of 10 studies, comprising 887 infants with hemangioma, were included. The response rate was reported in eight trials; these studies compared the topical timolol to laser, observation, placebo, or propranolol. The heterogeneity was statistically significant (P < 0.00001, I² = 83%). The difference in the response rate was significant (RR = 2.86, 95% CI 1.31-6.24) while comparing the topical timolol to the controls. However, no significant difference in the response rate was observed while comparing the topical timolol to propranolol (RR = 0.99, 95% CI 0.70-1.42). The difference in the adverse events was found to be significant (RR = 0.21, 95% CI 0.05-0.97) when the timolol group was compared to the control group. This meta-analysis confirmed that the topical timolol alone was more beneficial on response rate and adverse event than laser, placebo, and observation. The response rate did not differ significantly when comparing the topical timolol to propranolol. However, further studies are essential using an improved design of the study.

Adverse Events in Young and Preterm Infants Receiving Topical Timolol for Infantile Hemangioma

BACKGROUND

The success of oral propranolol for treatment of infantile hemangiomas (IHs) has led practitioners to use topical β-blockers. In preterm infants, clinicians frequently turn to topical timolol, with the presumption that topical application will result in less systemic absorption. We used Holter monitoring to assess for drug-induced bradycardia in high-risk infants.

METHODS

We retrospectively reviewed the charts of 22 at-risk infants who received a Holter monitor to assess for association between timolol administration and development of significant bradycardia.

RESULTS

Four infants had episodic bradycardia detected by Holter monitoring. Two of these infants were full term; weighed more than 3,000 g; and had rare, brief, asymptomatic episodes unrelated to the timing of the timolol application. The other two infants had symptomatic bradycardia while on timolol and were the only two babies that weighed less than 2,500 g at initiation of therapy. Both were young (postmenstrual age [PMA] 34 and 37 wks) at initiation and had a timolol dose above the average exposure for the cohort.

CONCLUSION

In this cohort of at-risk infants, topical timolol appeared to provide safe treatment for IHs in full-term infants receiving a dose of less than 0.2 mg/kg/day, but infants with a PMA of less than 44 weeks and weight at treatment initiation of less than 2,500 g may be at risk of adverse events, including bradycardia, hypotension, apnea, and hypothermia. We recommend close monitoring of temperature, blood pressure, and heart rate in premature and low-birthweight infants with IHs at initiation of and during therapy with topical timolol.

Topical timolol solution versus laser in treatment of infantile hemangioma: a comparative study

Lasers, 595-nm pulsed dye and 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG), have been used successfully for the treatment of infantile hemangiomas (IHs). Recently the use of a topical β-blocker, specifically timolol maleate, has been promising in the treatment of IHs. The objective of this study was to compare the effectiveness of topical timolol 5 mg/mL solution with that of combined sequential dual-wavelength laser in the treatment of IHs. Sixty children with IHs were divided randomly into two equal groups. Group 1 was treated with applications of timolol drops (5 mg/mL) twice daily. Group 2 was treated with sequential pulsed dye and Nd:Yag laser. Treatments were performed every month for a maximum of six sessions. Efficacy was evaluated clinically and by measuring the average hemoglobin level. A significant decrease in the average hemoglobin level was determined in both groups and a dramatic response was observed in superficial hemangiomas in the timolol group. The timolol group received treatment for an average of 4.0 ± 1.1 months and the laser group for 5.5 ± 0.9 months. The degree of improvement of mixed hemangiomas to laser treatment was greater than that of the timolol group. During 3 months of follow-up, no further improvement or relapse was reported in either group. Timolol solution is a safe and effective alternative to laser treatment in superficial hemangiomas. In mixed hemangiomas, the combined sequential 595-nm and 1,064-nm dual-wavelength laser provided better results than timolol solution because it penetrated deeply so that deep dermal blood vessels were reached.

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.

The use of propranolol in the treatment of infantile haemangiomas: an update on potential mechanisms of action

Currently, propranolol is the preferred treatment for problematic proliferating infantile haemangiomas (IHs). The rapid action of propranolol has been shown to be especially dramatic in IHs involving dyspnoea, haemodynamic compromise, palpebral occlusion or ulceration. Another remarkable aspect of propranolol treatment revealed that the growth of the IHs was not only stabilized, but also that the improvement continued until complete involution was achieved, leading to a considerable shortening of the natural course of IH. However, the mechanisms underlying the effects of propranolol have not been fully elucidated. Recent studies have offered evidence of a variety of mechanisms. These include the promotion of pericyte-mediated vasoconstriction, the inhibition of vasculogenesis and catecholamine-induced angiogenesis, the disruption of haemodynamic force-induced cell survival, and the inactivation of the renin-angiotensin system. This review summarizes these mechanisms and the new concepts that are emerging in this area of research. Moreover, several molecular mechanisms by which propranolol may modify neovascularization in IH have also been proposed. The antihaemangioma effect of propranolol may not be attributable to a single mechanism, but rather to a combination of events that have not yet been elucidated or understood. Further studies are needed to evaluate and verify these mechanisms to gain a greater understanding of the effects of the intake of propranolol on haemangioma involution.

Periocular hemangiomas and lymphangiomas

Infantile hemangiomas are the most common benign tumor of childhood. Lymphangiomas are benign hamartomatous vascular tumors. Both lesions can be problematic when located in the periocular region. Pediatricians must be familiar with the characteristics of each which would necessitate referral to an ophthalmologist or other subspecialist for evaluation, including obstruction of the visual axis which can lead to amblyopia of the affected eye. Additional potential complications include proptosis, ocular motility limitation, optic nerve injury, and poor eyelid closure with or without corneal surface disease. All children with periocular hemangiomas or lymphangiomas should be referred to an ophthalmologist for further evaluation.

Fractional carbon dioxide laser-assisted drug delivery of topical timolol solution for the treatment of deep infantile hemangioma: a pilot study

Infantile hemangiomas (IHs) are benign vascular tumors of infancy. Topical timolol has recently been reported to be an effective treatment for superficial IHs, although it failed to have an effect on deep IHs. This prospective study was aimed at evaluating the feasibility of ablative fractional laser-assisted drug delivery for enhancing topical timolol permeation into deep IHs. Nine patients ages 1 to 6 months with deep IHs were enrolled. A fractional carbon dioxide (CO2 ) laser system was applied to the skin surface of deep IHs using the DeepFx mode (25-30 mJ/pulse, 5% density, single pulse) at 1-week intervals. Topical timolol maleate 0.5% ophthalmic solution was applied under occlusion for 30 minutes four to five times per day for an average treatment duration of 14.2 weeks. Clinical improvement was evaluated according to a global score and the Hemangioma Activity Score (HAS). Four patients (44.4%) demonstrated excellent regression, four (44.4%) showed good response, and one (11.1%) experienced moderate regression. The HAS declined from 4.1 ± 0.7 at baseline to 1.7 ± 0.7 at 1 week (p < 0.001) and 1.4 ± 0.7 at 3 months (p = 0.03) after the last treatment procedure. Plasma timolol concentration was not detected in any of the patients after the first administration of topical timolol. No systemic complication or skin side effects were observed in any of the patients. Ablative fractional laser-assisted transdermal delivery of topical timolol is a safe and effective method for the treatment of deep IHs.

Treatment of superficial infantile hemangiomas with timolol: Evaluation of short-term efficacy and safety in infants

Timolol has been demonstrated to be efficacious in the topical treatment of superficial infantile hemangiomas (IHs). We conducted a prospective study to evaluate the short-term efficacy and safety of timolol in the treatment of superficial IH in Chinese infants. From March to November 2012, 124 patients with superficial IHs were included in the prospective study. The patients were divided into two groups: treatment (101 patients, the timolol drops were administered on the surface of the lesions three times daily, and erythromycin ointment was applied around the lesions) and observation (23 patients, without treatment). The results were categorized into three grades: class 1 (ineffective), class 2 (controlled growth) and class 3 (promoted regression). Within one week of the initiation of timolol treatment, a number of the lesions became softer and lighter in color. Four months following the initiation of timolol treatment, the overall response was class 1 in eight patients (7.9%), class 2 in 36 patients (35.6%) and class 3 in 57 patients (56.4%). Complete tumor regression was observed in 12 patients. No adverse effects were recorded during the treatment period. Among the patients in the observation group, there were 15 class 1 patients (65.2%), seven class 2 patients (30.4%) and only one class 3 patient (4.3%). In conclusion, timolol is an effective and safe treatment for superficial IH. In addition, it may be used in the treatment of proliferative superficial IH, particularly in infants within 6 months of age.

RCT of timolol maleate gel for superficial infantile hemangiomas in 5- to 24-week-olds

OBJECTIVE

Timolol maleate 0.5% gel is a safe and effective medication for treating superficial infantile hemangiomas (IHs) in infants with a median age of 9 weeks.

METHODS

Forty-one infants who had superficial IHs without ulceration and not near mucosal surfaces were recruited and randomly assigned to placebo and treatment (timolol maleate 0.5% gel) groups. Efficacy was assessed by performing blinded volume measurements at weeks 0, 1, 2, 3, 4, 8, 12, 16, 20, and 24 and blinded investigator photograph scoring at weeks 0, 12, and 24. Safety was assessed by measuring heart rate and systolic and diastolic blood pressure at weeks 0, 1, 2, 3, 4, 8, 12, 16, 20, and 24.

RESULTS

Fifteen of the 19 infants receiving treatment and 17 of the 22 infants receiving placebo completed the study. Significant color change on the blinded photographic scores was noted at week 24 of the study (P = .003). There was a significantly higher proportion of treated IHs that reduced in size by >5% at weeks 20 and 24 (P < .02). The predicted proportion of IH volume change was also significantly less for treated IHs from week 16 onward when compared with placebo (P < .05). There was no significant variation in blood pressure and heart rate between the groups.

CONCLUSIONS

Topical timolol maleate 0.5% gel with a maximum dose of 0.5 mg per day is a safe and effective option for small superficial IHs that have not ulcerated and are not on mucosal surfaces.

Imiquimod 5% cream versus timolol 0.5% ophthalmic solution for treating superficial proliferating infantile haemangiomas: a retrospective study

BACKGROUND

Infantile haemangiomas (IHs) are the most common vascular tumours of infancy. Topical therapies are a possible treatment for superficial IHs.

AIM

To determine the efficacy and safety of topical therapy in the treatment of superficial proliferating IHs.

METHODS

The medical records of all the patients with proliferating superficial IHs were reviewed. All lesions had been treated either with imiquimod 5% cream or timolol 0.5% ophthalmic solution. Lesions were classified into pairs, with one of each treatment in each pair, matched by anatomical location, colour and size. A visual analogue scale (VAS) and the Haemangioma Activity Score (HAS) were used to evaluate the efficacy of the two drugs. The paired Student t-test was used to test for differences in recovery with these two treatments.

RESULTS

In total, 51 patients treated with timolol and 94 treated with imiquimod met the inclusion criteria, and 20 lesions treated with timolol were successfully matched to a lesion treated with imiquimod. The paired t-test indicated that there was no significant difference in either VAS score (P = 0.11) or HAS (P = 0.49). For the imiquimod-treated patients, crusting was the most common reaction (65.0%, 13/20). This did not cause any superficial scarring or skin pigmentation in the matched pairs; however, superficial scars (14.9%, 14/94) and skin pigmentation disorders (28.7%, 27/94) were reported for some of the unmatched cases. There were no adverse events (AEs) during the treatment with timolol.

CONCLUSIONS

Both imiquimod 5% cream or timolol 0.5% ophthalmic solution showed equivalent clinical efficacy after 4 months of treatment. Timolol appeared to have fewer AEs than imiquimod in the management of superficial IHs. Larger, prospective controlled trials with long-term treatment are needed to confirm these results.

Management of infantile hemangiomas : current and potential pharmacotherapeutic approaches

Infantile hemangiomas (IH), benign vascular neoplasms, are the most common tumors of infancy and childhood. Most IH are medically insignificant; however, a proportion will require treatment because of interference with vital structures, threat of significant disfigurement, ulceration, or bleeding. This article reviews current and potential pharmacotherapeutic approaches to the treatment of IH. While corticosteroids have long been considered the mainstay of medical therapy for IH, several new treatments have recently emerged, the most promising of which is oral propranolol. Topical timolol and imiquimod are additional new therapies that may also prove to be effective, particularly for the treatment of superficial IH.

Early Surgical Excision of Giant Congenital Hemangiomas of the Scalp in Newborns: Clinical Indications and Reconstructive Aspects

Background:

Infantile hemangioma is the most common vascular tumor in newborns, with an incidence from 12 to 23% among preterm infants with low weight at birth and a female to male ratio of 3:1. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions.

Objective:

We describe some clinical and medical aspects in comparison with the surgical approach to giant infantile hemangioma of the scalp.

Methods:

The indications to treatment are discussed. An outcome basis evaluation, by reviewing some clinical cases, is provided to help readers better understand when and how to undergo surgery safely.

Conclusion:

Early excision of huge infantile hemangioma of the scalp is the treatment of choice if feasible within 5 months of age.

Infantile hemangiomas: an update on pathogenesis and therapy

Infantile hemangiomas (IHs) are the most common vascular tumors of childhood, affecting ~5% of all infants. Although most lesions proliferate and then involute with minimal consequence, a significant minority can be disfiguring, functionally significant, or, rarely, life-threatening. Recent discoveries concerning hemangioma pathogenesis provide both an improved understanding and more optimal approach to workup and management. Important detrimental associations can be seen with IH, such as significant structural anomalies associated with segmental IH. Standards of care have dramatically changed evaluation and management of hemangiomas. The goal of timely recognition and therapy is to minimize or eliminate long-term sequelae. New modalities, such as oral propranolol, provide the caregiver with better therapeutic options, which can prevent or minimize medical risk or scarring, but the side effect profile and risk-benefit ratio of such interventions must always be evaluated before instituting therapy.

Evaluation of skin permeation of β-blockers for topical drug delivery

PURPOSE

β-Blockers have recently become the main form of treatment of infantile hemangiomas. Due to the potential systemic adverse effects of β-blockers, topical skin treatment of the drugs is preferred. However, the effect and mechanism of dosage form pH upon skin permeation of these weak bases is not well understood. To develop an effective topical skin delivery system for the β-blockers, the present study evaluated skin permeation of β-blockers propranolol, betaxolol, timolol, and atenolol.

METHODS

Experiments were performed in side-by-side diffusion cells with human epidermal membrane (HEM) in vitro to determine the effect of donor solution pH upon the permeation of the β-blockers across HEM.

RESULTS

The apparent permeability coefficients of HEM for the β-blockers increased with their lipophilicity, suggesting the HEM lipoidal pathway as the main permeation mechanism of the β-blockers. The pH in the donor solution was a major factor influencing HEM permeation for the β-blockers with a 2- to 4-fold increase in the permeability coefficient per pH unit increase. This permeability versus pH relationship was found to deviate from theoretical predictions, possibly due to the effective stratum corneum pH being different from the pH in the donor solution.

CONCLUSIONS

The present results suggest the possibility of topical treatment of hemangioma using β-blockers.

Current concepts in the management of periocular infantile (capillary) hemangioma

PURPOSE OF REVIEW

To review and evaluate the medical literature on new treatments for periocular infantile (capillary) hemangioma. Recent studies have shown a promising new therapy for infantile hemangioma using nonselective β-blockers, including oral propranolol and topical timolol.

RECENT FINDINGS

Conventional treatments for infantile hemangioma include the use of corticosteroids, laser, surgery, and immunomodulator therapy. Recently, systemic and topical β-blockers have been used to successfully treat infantile hemangioma. The drugs' mechanism of action remains uncertain, but plausible theories include vasoconstriction, modulation of pro-survival signal transduction pathways, and endothelial cell apoptosis. Whereas no life-threatening adverse events from β-blocker treatment have been described, there have been reports of bradycardia, hypotension, bronchospasm, hypoglycemia, and electrolyte disturbances resulting from systemic use of propranolol to treat infantile hemangioma. Sleep and gastrointestinal disturbances have also been frequently reported. Topical timolol application for localized, superficial tumors may confer similar efficacy as oral propranolol while reducing systemic effects.

SUMMARY

Despite the recent explosion of interest surrounding this novel treatment, current treatment and protocol-monitoring recommendations are based largely on the experience of individual centers. Several randomized controlled studies are currently underway, the results of which will guide future standard-of-care treatment for infantile hemangioma.

Timolol maleate 0.5% or 0.1% gel-forming solution for infantile hemangiomas: a retrospective, multicenter, cohort study

Therapeutic options for superficial infantile hemangiomas (IH) are limited. Recently, timolol maleate gel, a topical nonselective beta-blocker, has been reported as a potentially effective treatment for superficial IH. This study is an extension of a previously published pilot study designed to further investigate the efficacy and safety and to identify predictors of good response of topical 0.5% or 0.1% timolol maleate gel-forming solution. This was a retrospective cohort study including patients enrolled from five centers. Patients were included if they were treated with timolol maleate 0.1% or 0.5% gel-forming solution and had photographic documentation of the IH and at least one follow-up visit. Patients with concomitant active treatment using other IH treatments were excluded. The primary endpoint was change in the appearance of IH as evaluated using a visual analog scale (VAS). Data from 73 subjects were available for final analysis. Timolol maleate gel-forming solution 0.5% was used in 85% (62/73) of patients, the remainder being treated with 0.1%. The median age at treatment initiation was 4.27 months (interquartile range [IQR] 2.63-7.21 mos), and patients were treated for a mean of 3.4 ± 2.7 months. All patients except one improved, with a mean improvement of 45 ± 29.5%. Predictors of better response were superficial type of hemangioma (p = 0.01), 0.5% timolol concentration (p = 0.01), and duration of use longer than 3 months (p = 0.04). Sleeping disturbance was noted in one patient. This study further demonstrates the efficacy and tolerability of topical timolol maleate and gradual improvement with longer treatment in patients with superficial IH.

Treatment of small superficial haemangioma with timolol 0.5% ophthalmic solution: a series of 20 cases

BACKGROUND

Haemangioma of infancy (HOI) on the face may be disfiguring and alarming for parents. Usually they are not treated when they are small. Treatment of HOI with propranolol is a breakthrough. Timolol (topical treatment) and propranolol are closely related.

METHODS

We considered topical treatment with timolol 0.5% ophthalmic solution 3-4 times daily in patients with small HOI. Twenty patients with small mostly superficial HOI were included.

RESULTS

A series of 20 patients with HOI treated with timolol 0.5% ophthalmic solution are described. The treatment was effective in all superficial HOIs after 1-4 months. A quick direct inhibitory effect on the growth of the HOI followed by slower regression was observed. The children had to be treated during the whole proliferative phase. Deep HOIs on the nose (2 cases) and lower eyelid (1 case) showed no response.

CONCLUSION

Topical timolol 0.5% ophthalmic solution is effective in HOI. Safety and effectiveness of drugs like topical timolol and topical propranolol require further investigation but they seem very safe when used in small HOIs. We recommend that small superficial HOIs should be treated in an early proliferative phase.