Oral propranolol therapy for infantile hemangiomas beyond the proliferation phase: a multicenter retrospective study

A retrospective analysis of infantile haemangioma referrals: a comparison with the IH European Task Force 'Infantile Haemangioma Referral Score'

BACKGROUND

Infantile haemangiomas (IH) are common vascular tumours of infancy that can have significant complications. The IH European Task Force developed the IH Referral Score (IHReS) to help non-specialists quickly identify IH that need to be referred to optimise outcomes in high-risk lesions.

AIMS

The aim of this study was to assess the quality of IH referrals to a national care centre and compare the IH referred to the IHReS tool.

METHODS

This was a retrospective cross-sectional study that collected data from a random sample of 56 IH patients over a 13-month period.

RESULTS

Less than 10% included a photograph (8.93%) and a minority of referrals included if there were complications including ulceration (1.79%) or function threatening (8.93%). Three-quarters of patients satisfied the IHReS criteria.

CONCLUSION

The IHReS screening tool is a convenient and efficient resource for non-experts to identify children who require referral to a specialist centre.

Development of a digital imaging analysis system to evaluate the treatment response in superficial infantile hemangiomas

Superficial infantile hemangiomas (IH) are benign vascular tumors common in children characterized by bright red "strawberry" lesions on the skin. In order to optimize the treatment for this disease, there is a need to develop objective tools to assess treatment response. Since a color change in the lesion is a good indicator of treatment response, we have developed a digital imaging system to quantify the values of red, green, and blue (RGB) difference and RGB ratio between the tumor and normal tissue to take into account the variations in color between different skin types. The efficacy of the proposed system in assessing treatment response in superficial IH was evaluated in relation to established visual and biochemical tools used to grade hemangiomas. As the treatment progressed, the RGB ratio was almost 1, while the RGB difference was close to 0, which indicates a good response to treatment. There was a strong correlation between the RGB score and the other visual grading systems. However, the correlation between the RGB scoring system and the biochemical method was weak. These findings suggest that the system can be used clinically to objectively and accurately evaluate disease progression and treatment response in patients diagnosed with superficial IH.

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.

Ultrasound and MRI findings as predictors of propranolol therapy response in patients with infantile hemangioma

OBJECTIVES

To evaluate the prognostic value of ultrasound and MRI findings in patients with infantile hemangioma undergoing propranolol therapy.

METHODS

This study was based on retrospective interpretation of prospectively acquired data. Thirty-eight consecutive patients (28 females and 10 males; mean age ± standard deviation, 3.2 ± 2.2 months) who underwent propranolol treatment for infantile hemangioma were included. Pre-treatment ultrasound images were assessed in terms of echogenicity, lesion height and vascularity. Presence of prominent intratumoral fat, non-fat septa, and enhancement pattern on MRI were retrospectively evaluated. Mann-Whitney test, chi-square, and Fisher's exact tests were used to compare imaging parameters between patients with treatment success and failure.

RESULTS

All patients underwent ultrasound and 15 patients underwent MRI. A total of 24 patients showed successful treatment. Between patients with treatment success and failure, there were significant differences in increased vascularity on pre-treatment ultrasound (19/24 vs. 6/14, p = 0.025), decreased vascularity on post-treatment ultrasound (21/24 vs. 5/14, p = 0.001), and prominent intratumoral fat on MRI (1/8 vs. 5/7 p = 0.033). There were no significant differences in echogenicity, lesion height on ultrasound, non-fat septa and MR enhancement pattern.

CONCLUSIONS

Increased vascularity on pre-treatment ultrasound was significantly associated with successful treatment for propranolol therapy in patients with infantile hemangioma, whereas prominent fat component on MRI was significantly associated with treatment failure.

Infantile Hemangioma: An Updated Review

BACKGROUND

Infantile hemangiomas are the most common vascular tumors of infancy, affecting up to 12% of infants by the first year of life.

OBJECTIVE

To familiarize physicians with the natural history, clinical manifestations, diagnosis, and management of infantile hemangiomas.

METHODS

A Pubmed search was conducted in November 2019 in Clinical Queries using the key term "infantile hemangioma". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

The majority of infantile hemangiomas are not present at birth. They often appear in the first few weeks of life as areas of pallor, followed by telangiectatic or faint red patches. Then, they grow rapidly in the first 3 to 6 months of life. Superficial lesions are bright red, protuberant, bosselated, or with a smooth surface, and sharply demarcated. Deep lesions are bluish and dome-shaped. Infantile hemangiomas continue to grow until 9 to 12 months of age, at which time the growth rate slows down to parallel the growth of the child. Involution typically begins by the time the child is a year old. Approximately 50% of infantile hemangiomas will show complete involution by the time a child reaches age 5; 70% will have disappeared by age 7; and 95% will have regressed by 10 to 12 years of age. The majority of infantile hemangiomas require no treatment. Treatment options include oral propranolol, topical timolol, and oral corticosteroids. Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration in areas where serious complications might ensue, interference with vital structures, life- or function-threatening complications, and significant disfigurement.

CONCLUSION

Treatment should be individualized, depending upon the size, rate of growth, morphology, number, and location of the lesion (s), existing or potential complications, benefits and adverse events associated with the treatment, age of the patient, level of parental concern, and the physician's comfort level with the various treatment options. Currently, oral propranolol is the treatment of choice for high-risk and complicated infantile hemangiomas. Topical timolol may be considered for superficial infantile hemangiomas that need to be treated and for complicated infantile hemangiomas in patients at risk for severe adverse events from oral administration of propranolol.

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.

Retrospective case series of increased oral propranolol dosage for infantile hemangiomas

BACKGROUND

Infantile hemangiomas (IH) are the most common benign tumor of infancy. Although oral propranolol is currently first-line therapy, optimal dosing for treatment of IH remains debated. We sought to identify hemangioma characteristics associated with poor response to standard dosing (2 mg/kg/d) and to assess the therapeutic benefit of higher dosing.

METHODS

Retrospective chart review was conducted of 559 patients with IH seen at Johns Hopkins between 2008 and 2018, of whom 245 (44%) were treated with propranolol. Baseline characteristics were compared between patients who received increased propranolol dosing (≥2.5 mg/kg/d) and those who remained on standard dose (2 mg/kg/d). Changes in the Hemangioma Activity Score (HAS) during the increased dosage period were scored by two trained, blinded pediatric dermatologists.

RESULTS

Of 245 patients, 204 (83%) received standard 2 mg/kg/d propranolol dosing while 41 (17%) received a higher dose of ≥2.5 mg/kg/d. The most common location of IH in both groups was the face. In the increased dosage group, 85.4% of IH were of mixed or deep morphology with a mean greatest diameter of 4.6 cm. IH requiring increased dosing received longer courses of propranolol (mean of 389 vs. 282 days, P < .001) and underwent higher rates of excision by plastic surgery (26.8% vs. 5.9%, P < .001). Mean change in HAS over the period with dosage ≥2.5 mg/kg/d was minimal (-0.70; P < .001).

CONCLUSIONS

Most recalcitrant IH were located on the face, larger in diameter, and of mixed or deep morphology. Patients had little improvement in HAS score with increased propranolol dosing implemented late in the treatment course with over one-fourth ultimately receiving surgical excision.

Treatment of haemangiomas using propranolol in paediatric patients: a retrospective cohort study

Introduction

Haemangioma, one of the most common benign neoplasms of early childhood, is a significant clinical problem due to cosmetic reasons but also because of possible health complications.

Aim

Presentation of the method and results of treatment of infantile haemangiomas (IHs) using propranolol in a maximum dose of 3 mg/kg/day.

Material and methods

In 2013 to 2018 there were 108 patients with IHs multidisciplinary diagnosed and treated. 77 of them were girls and 31 were boys; all were between the ages of 2 and 21 months (mean: 6.87 months). Lesions were most often located in the head region (n = 73). The main imaging study assessing the arteriovenous flow was USG, which was used to assess the size of haemangioma and its regression or progression. Also, coagulation parameters were analysed using laboratory tests.

Results

Reduction of lesions occurred in 103 of 108 patients, which results in a percentage score above 95. In 19 patients, after completion of treatment, there were abnormalities of coagulation in laboratory tests whereas before the treatment, these abnormalities occurred in 82 patients. The average duration of treatment was longer than 12 months and the maximum dose of propranolol of 3 mg/kg/day was achieved after 3 to 5 months of treatment. Side effects occurred totally in 19 patients, with night anxiety and nightmares being the most common.

Conclusions

After achieving the maximum dose of the drug later than recommended in the Recommendation of the Polish Haemangioma and Vascular Malformations Group criteria, there was no need for longer therapy, while the effectiveness of the treatment remained unchanged. Side effects that occurred were not life-threatening or detrimental to the health of patients.

A new clinical and dermoscopic monitoring of infantile hemangiomas treated with oral propranolol

Oral propranolol (OP) demonstrated high efficacy and safety profile for treatment of critical infantile hemangiomas (IHs). Our aim was to assess the morphologic changes of IHs with standard and high-resolution video dermoscopy (HRVD) from baseline to 18 months either in presence or absence of OP therapy; to investigate if extended anamnestic perinatal data and clinical-dermoscopic characteristics of the IHs can correlate with therapeutic outcome. We enrolled 94 patients (112 IHs): 58 were treated with OP, 35 (42 IHs) for 6 months (group 1), and 23 (25 IHs) for 12-months (group 2); 36 (45 IHs) were followed-up. Clinical-dermoscopic examinations were performed every 3 months during therapy and follow-up. Among 67 treated IHs, superficial and deep IHs with homogenous clinical-dermoscopic aspect developed after the 2 weeks of life achieved the better outcome, stable at 9-month follow-up, independently form treatment duration. Under HRVD, glomerular vessels were prevalent at baseline; corckscrew, comma, and linear-irregular vessels were the prevalent pattern at 1, 3, and 6 months of therapy, respectively. At 12-month follow-up, adequate healing was achieved by 96% of IHs in group 2 and by 78% in group 1, showing dotted vessels. Persistent IHs displayed a reticulated aspect and linear irregular vessels, while arborizing vessels characterized relapsed IHs. A 12-month OP therapy can be considered for newborns presenting with nonhomogenous mixed IHs >3 cm on the perineal area/lower extremities. In conclusion, HRVD allows a real time monitoring of vascular changes in IHs treated with OP and can support physicians in identifying relapses before they become clinically evident.

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.

Clinical and Ultrasonographic Evaluation of Infantile Periocular Hemangioma Treated With Oral Propranolol

PURPOSE

To evaluate the clinical and ultrasonographic response of periocular infantile capillary hemangioma during treatment with oral propranolol.

METHODS

Patients with infantile periocular hemangioma and visual or cosmetic concerns were enrolled in this prospective interventional case series. Propranolol was given at a dose of 2 mg/kg per day for at least 6 months. Evaluation of treatment response was performed at month 3 (time point 1) and month 6 (time point 2). Gray scale ultrasonography and color Doppler imaging were performed at baseline and month 3.

RESULTS

Thirty-one patients with mean age of 4.1 ± 2.3 months were eligible for analysis. Complete or near complete clinical resolution was observed in 4 patients (12.9%) at time point 1 and 21 patients (67.7%) at time point 2. Longitudinal diameter, transverse diameter, thickness, arterial peak systolic velocity, and end diastolic velocity reduced significantly from baseline to 3-month follow up. Complete clinical response at time point 2 was significantly higher in patients with peak systolic velocity reduction >50% from baseline to month 3 than patients with peak systolic velocity reduction of 10% to 50% and <10%.

CONCLUSIONS

Propranolol is safe and effective for infantile periocular hemangioma. Ultrasonography and color Doppler imaging are useful modalities to monitor and predict the treatment response.

Current treatment and management of infantile hemangiomas

Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.

Efficacy and safety of oral atenolol for the treatment of infantile haemangioma: A systematic review

Recently, several studies have reported their experience in using oral atenolol in patients with infantile haemangioma (IH), especially as an alternative to propranolol, but the efficacy and safety of oral atenolol has not been evaluated. We searched PubMed (Medline), Central, Embase, Web of Science and EBSCOhost (until May 2018) for the eligible studies reporting more than 10 IH patients who were treated with oral atenolol with detailed original data, including outcomes, regimens and adverse events (AEs). The data was standardised and analysed by using R software with meta-package. A total of 9 of 141 identified articles, including 341 infantile haemangioma patients treated with oral atenolol therapy, were included. The pooled response rate of atenolol was 0.90 (95% CI: 0.85-0.93), and the rebound rate was 0.11 (95% CI: 0.08-0.16). Among the 341 patients, 44 patients were switched to atenolol therapy from propranolol due to adverse events. The response rate of subsequent atenolol treatment was 90.9% (40/44). Regarding AEs, 141 patients reported 177 episodes of AEs, and the pooled rate was 0.26 (95% CI: 0.12-0.47). Gastrointestinal symptoms (e.g. constipation, diarrhoea and vomiting) were the most frequent AEs (22.6%). Widely known propranolol-related AEs, including hypoglycaemia, bronchospasm, bradycardia and hypotension, were not recorded. Overall, atenolol appears to be an effective and safe therapy for the treatment of IH and may be a promising alternative to propranolol.

Oral propranolol for infantile hemangiomas beyond the proliferative phase

Infantile hemangiomas grow rapidly during infancy followed by gradual involution. After involution, residual lesions sometimes remain. Despite the prognosis for eventual involution, infantile hemangiomas often cause great psychosocial morbidity that affects patients and their parents. Oral propranolol usually induces earlier involution and redness reduction in infantile hemangiomas in the proliferative phase. However, to evaluate the effectiveness of oral propranolol for infantile hemangiomas beyond the proliferative phase is difficult because of spontaneous regression. We report five Japanese patients treated with 2 mg/kg per day of oral propranolol for infantile hemangiomas beyond the proliferative phase and compared with three untreated patients. After the oral propranolol treatment for 25 weeks, all the treated patients exhibited earlier color fading than untreated patients. Four patients reached nearly complete resolution. Adverse events occurred in three patients: cold, exanthema subitum and suspected of bronchial asthma, respectively. The propranolol treatment for the patient with suspected of bronchial asthma was suspended for 4 months. Recurrence after termination of treatment was not seen. Oral propranolol (2 mg/kg per day) is a safe and effective treatment for Japanese patients with infantile hemangiomas beyond the proliferative phase.

Current perspectives on the optimal management of infantile hemangioma

Infantile hemangiomas (IHs) are the most common benign tumor of infancy. As our understanding of their pathobiology has evolved, treatment has become more focused and tailored to specifically treat IH while minimizing adverse effects. Propranolol has gained FDA approval as the first medical therapy for a traditionally surgical disease. This review provides readers with an overview of IH, treatment modalities, and addresses specific considerations in IH disease management.

Cardiac arrest in a toddler treated with propranolol for infantile Hemangioma: a case report

Background

Propranolol has become the first-line treatment for complicated Infantile Hemangioma (IH), showing so far a good risk-benefit profile.

Case presentation

We report the case of a toddler, on propranolol, who suffered cardiac arrest during an acute viral infection. She had a neurally-mediated syncope that progressed to asystole, probably because of concurrent factors as dehydration, beta-blocking and probably individual susceptibility to vaso-vagal phenomena. In fact a significant history of breath-holding spells was consistent with vagal hyperactivity.

Conclusions

The number of patients treated with propranolol for IHs will increase and sharing experience will help to better define the safety profile of this drug.

Safety of Oral Propranolol for the Treatment of Infantile Hemangioma: A Systematic Review

BACKGROUND AND OBJECTIVES

Given the widespread use of propranolol in infantile hemangioma (IH) it was considered essential to perform a systematic review of its safety. The objectives of this review were to evaluate the safety profile of oral propranolol in the treatment of IH.

METHODS

We searched Embase and Medline databases (2007-July 2014) and unpublished data from the manufacturer of Hemangiol/Hemangeol (marketed pediatric formulation of oral propranolol; Pierre Fabre Dermatologie, Lavaur, France). Selected studies included ≥10 patients treated with oral propranolol for IH and that either reported ≥1 adverse event or effect (AE) or planned to capture AEs. Data capture was standardized and extracted study design, demographic characteristics, IH characteristics, intervention, and safety outcomes. AEs were assigned a system organ class and preferred term.

RESULTS

A total of 83 of 398 identified literature records met the inclusion criteria, covering 3766 propranolol-treated patients. The manufacturer's data for 3 pooled clinical trials (435 propranolol-treated patients) and 1 Compassionate Use Program (1661 patients) were included. AE data were reported for 1945 of 5862 propranolol-treated patients. The most frequently reported AEs included a range of sleep disturbances, peripheral coldness, and agitation. The most serious AEs (atrioventricular block, bradycardia, hypotension, bronchospasm/bronchial hyperreactivity, and hypoglycemia-related seizures) were managed by decreasing doses or temporary/permanent discontinuation of propranolol. Limitations included the variety of included study designs; monitoring, collection, and reporting of AE data; small sample sizes for some articles; and the wide scope of review.

CONCLUSIONS

Oral propranolol is well tolerated if appropriate pretreatment assessments and within-treatment monitoring are performed to exclude patients with contraindications and to minimize serious side effects during treatment.

Hemangioma treatment with pulsed dye laser-distinct parameters used between neonatal and non-neonatal patients

BACKGROUND

Pulsed dye laser (PDL) treatment remains the standard of care for infantile hemangiomas (IHs). However, the use of PDL to treat IHs in neonates has been hardly reported. In this study, the PDL treatments of IHs between neonatal and non-neonatal patients were retrospectively investigated.

METHODS

All patients diagnosed with hemangiomas were treated by PDL. Their clinical data were collected, and the treatment outcomes and PDL parameters in neonates and non-neonates were analyzed using the Mann-Whitney U-rank test.

RESULTS

All patients reached good or excellent scale in the treatment efficiency assessment. Laser energy used per treatment session was significantly lower in neonatal group than in non-neonatal group (Z = -8.980, P < 0.001). Total laser energy used in neonates was also markedly lower than that in non-neonatal patients (Z = -3.065, P = 0.002). However, treatment session numbers in these two groups were not significantly different (Z = -1.725, P = 0.085). Additionally, we observed that after each treatment, the purpura disappeared faster in neonates (2-4 weeks) than in non-neonatal patients (4-6 weeks), indicating neonates might have greater recovery ability.

CONCLUSIONS

PDL, with distinct parameters, was effective in the treatment of IHs in neonates. After each laser treatment, neonates recovered faster than non-neonatal patients.

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.

Ocular manifestations of Sturge-Weber syndrome: pathogenesis, diagnosis, and management

Sturge–Weber syndrome has been included in the group of phakomatoses that is characterized by hamartomas involving the brain, skin, and eyes. The characteristic facial port-wine stain, involving the first branch of the trigeminal nerve and the embryonic vasculature distribution in this area, leads to several ocular complications of the anterior segment and can involve the eyelids and conjunctiva. The posterior segment of the eyes is also affected with diffuse choroidal hemangiomas. However, the most frequent ocular comorbidity is glaucoma with a prevalence rate ranging from 30%–70%. Glaucoma is related to anterior chamber malformations, high episcleral venous pressure (EVP), and changes in ocular hemodynamics. Glaucoma can be diagnosed at birth, but the disease can also develop during childhood and in adults. The management of glaucoma in Sturge–Weber syndrome patients is particularly challenging because of early onset, frequently associated severe visual field impairment at the time of diagnosis, and unresponsiveness to standard treatment. Several surgical approaches have been proposed, but long-term prognosis for both intraocular pressure control and visual function remains unsatisfactory in these patients. Choroidal hemangiomas may also lead to visual impairment thorough exudative retinal detachment and macular edema. Treatment of exudative hemangioma complications is aimed at destructing the tumor or decreasing tumor leakage.

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.

Oral Propranolol for the Treatment of Infantile Hemangiomas in the Post-Proliferative Phase: A-Single Center Retrospective Study of 31 Cases

PURPOSE

Infantile hemangiomas (IHs) are the most common benign tumors affecting infants, and most IHs are self-limiting. However, there are cases that require specific treatment. Propranolol is now widely used to treat severe IHs. Several studies have shown the efficacy and limited side effects associated with propranolol as the first-line treatment for IHs. There are a limited number of publications describing the role of propranolol in treating IHs beyond the proliferative phase (>12 months). The purpose of this study was to evaluate the effects and safety of oral high-dose (2.0 mg/kg per day) propranolol for IHs beyond the proliferative phase (>12 months).

PATIENTS AND METHODS

This study enrolled patients with IHs who accepted systemic propranolol treatment from the Department of Oral and Maxillofacial Surgery, Stomatological Hospital Affiliated China Medical University. This is a single-center retrospective study conducted from April 2011 to July 2015. All children who were older than 12 months were eligible for the study. Digital photographs taken before and after treatment were analyzed by a panel of 3 plastic surgeons. The esthetic results were evaluated using a 4-point scale and ranked as poor, moderate, good, or excellent. The patient follow-up visits were scheduled monthly, and changes in the size, texture, and color of the lesions were recorded. The adverse effects after medication were evaluated and managed accordingly.

RESULTS

We collected data on 31 eligible patients. The 31 patients had 32 hemangiomas (1 female patient had 2 lesions) and were treated with systemic propranolol at a high dose of 2 mg/kg per day. The mean age at the initiation of propranolol therapy was 18.4 months (range, 12 to 48 months), and the mean treatment duration was 10.1 months (range, 8 to 16 months). The treatment responses for the 32 hemangiomas included 17 excellent responses (53.1%), 8 good responses (25%), and 7 moderate responses (21.9%). There were no severe side effects encountered and recurrence was observed in 3 patients during the treatment and follow-up course.

CONCLUSIONS

Oral propranolol, 2 mg/kg per day, is a safe and effective treatment for IHs beyond the proliferative phase (>12 months of age) in the Chinese population.

Hemangiomas and the eye

Infantile hemangiomas are a common vascular birthmark with heterogeneous presentations and unique growth characteristics with early rapid growth and eventual self-involution. Hemangiomas that develop around the eye have the potential for inducing amblyopia by several mechanisms and may eventually result in permanent visual impairment in otherwise healthy infants. Segmental periocular hemangiomas carry the additional risk of associated structural anomalies and PHACE syndrome. In recent years, the treatment of periocular hemangiomas has been revolutionized by the serendipitous discovery of the effectiveness of beta-blockers (systemic and topical), with most experts viewing these as first-line therapies. The management of periocular hemangiomas should involve a close partnership between an ophthalmologist and dermatologist or other relevant specialists familiar with the unique clinical features, differential diagnosis, treatment approaches, and potential complications.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Effectiveness and Safety of Oral Propranolol versus Other Treatments for Infantile Hemangiomas: A Meta-Analysis

BACKGROUND

Epidemiological studies evaluating treatments for infantile hemangiomas have produced inconsistent results. A meta-analysis of published data was conducted to investigate the effectiveness and safety of oral propranolol versus other treatments for infantile hemangiomas.

METHODS

A meta-analysis was conducted based on literature (published from 1960 to December 1, 2014) found on the PubMed, EMBASE, and OVID search engines. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for the outcome measures. Heterogeneity, publication bias and subgroup analysis were performed.

RESULTS

A total of 61 studies involving 5,130 participants met the inclusion criteria. Propranolol was found to be a more effective modality in treating IHs (ORs = 0.92; 95%CI, 0.89-0.95) and had fewer complications compared to the other treatments including systemic steroids (ORs = 0.68; 95% CI, 0.59-0.76); laser ablation (ORs = 0.55; 95% CI, 0.43-0.67); other beta-adrenergic blockers (ORs = 0.56; 95% CI, 0.50-0.61) and surgery (ORs = 0.55; 95% CI, 0.28-0.81). A subgroup analysis of propranolol showed that a dose of 2 mg/kg/day or more yielded better outcomes (ORs = 0.92; 95% CI, 0.88-0.95; ORs = 0.95; 95% CI, 0.89-1.00), and IHs that had not been previously treated had better responses to propranolol treatment (ORs = 0.95; 95% CI, 0.91-0.98).

CONCLUSIONS

The meta-analysis demonstrated that propranolol was more effective and safer than other therapies in treating IHs. It provides strong evidence for supporting the use of propranolol as a first-line therapy for IHs.

Oral Nadolol for the Treatment of Infantile Hemangiomas: A Single-Institution Retrospective Cohort Study

BACKGROUND

Beta-blockers have become the treatment of choice for problematic infantile hemangiomas (IHs). Nadolol, a nonselective beta-blocker with potential dosing advantages and a better safety profile than that of other beta-blockers, has been studied as an alternative therapeutic option. Our objective was to characterize the efficacy and safety of oral nadolol in the treatment of proliferating IHs.

METHODS

A retrospective cohort study was conducted at the Hospital for Sick Children between February 2010 and April 2012 in patients treated with nadolol for proliferating IHs causing functional impairment or cosmetic disfigurement. The primary outcome was the percentage involution measured independently by two assessors who scored changes in the extent of IHs by comparing serial photographs using a 100-mm visual analogue scale (VAS), on which 5 mm represented 10% change.

RESULTS

Forty-four patients treated with nadolol for IHs with adequate photographic documentation were identified. The median age at presentation was 4.5 months (interquartile range 1.5-7.9 mos). There was a mean improvement of 91.8 ± 11.1%. At least 50% improvement was noted in 42 (95%) patients and 75% improvement in 39 (89%) patients. The mean time to 50% and 75% improvement was 2.9 and 3.7 months, respectively. Analysis of variance showed that younger age at the time of treatment start was associated with a higher mean VAS score (% involution) (p < 0.05). Treatment duration (mean 9.5 ± 5.6 months) had no significant effect on VAS score. Test of interobserver correlation showed good agreement (intraclass correlation coefficient = 0.86, p = 0.001).

CONCLUSIONS

Oral nadolol is efficacious in patients with problematic IHs. Further large-scale prospective comparative studies are warranted to compare nadolol with other beta-blockers.

Effectiveness of propranolol in the treatment of infantile hemangioma beyond the proliferation phase

During the last 5 years, many studies have shown the efficacy of propranolol as first-line treatment for infantile hemangiomas (IHs), but not much has been written about the role of propranolol beyond the proliferation phase of IH (>1 year). Our aim was to assess propranolol efficacy and safety in the treatment of patients older than 1 year. A retrospective study of patients older than 1 year diagnosed with IH and treated in our vascular anomalies clinic between 2009 and 2013 was performed. Eighteen patients older than 1 year with a diagnosis of IH (15 girls, 3 boys) were identified. The mean age at the time of initiation of treatment was 25.7 months (range 13-72 mos). Single lesions were observed in 13 patients and multiple lesions in 5. Fifteen patients had focal lesions and three had segmental. The median duration of treatment with oral propranolol was 11.8 months (range 2-33 mos). Complete response was observed in 72.2% of the patients and partial response in 27.8%. Recurrence was observed in three patients 4.7 months after completion of therapy (range 0.3-8 mos). These patients required further therapy with propranolol for 6 more months. Bradycardia was documented in two patients and night terrors in one patient, which led to discontinuation of treatment. In our experience, propranolol may be useful in the treatment of IHs beyond the proliferation phase (>1 year old), but more studies are needed to support this observation.

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.

Infantile haemangiomas that failed treatment with propranolol: clinical and histopathological features

AIM

To describe the clinical and histopathological characteristics of infantile haemangiomas that failed treatment with oral propranolol .

DESIGN

This study is a case series from the vascular birthmarks clinic at Royal Children's Hospital, Melbourne.

PATIENTS

The patients for this study were infants who commenced treatment with oral propranolol before 6 months of age and who were treated for at least 4 months without a satisfactory result. For histology and immunohistochemistry, tissue from the four non-responding patients who subsequently underwent surgical excision was matched with four historical controls.

OUTCOME MEASURES

Based on medical record review and photographic assessments, infants were defined as having failed treatment with oral propranolol if the infantile haemangioma either continued to grow or showed 20% improvement or less. Tissue sections were examined for tissue structure, mast cells, sympathetic innervations and beta-2 adrenergic receptor expression, and the number of mast cells and beta-2 adrenergic positive cells.

RESULTS

From a group of 135 infants who met the inclusion criteria, 14 infants failed propranolol treatment. Eleven of these infants had focal facial haemangiomas. No difference was seen in tissue morphology, tissue innervations, beta-2 adrenergic receptor expression, cell number or mast cell distribution, and number between non-responding and control haemangiomas.

CONCLUSION

We report a treatment failure rate of 10%, which is higher than previously reported. Focal facial lesions failed to respond twice as frequently as other types of haemangioma. No histopathological reason was identified to indicate why some haemangiomas failed to respond.

The effect of oral propranolol on intraocular pressure in infants with Sturge-Weber syndrome glaucoma

PURPOSE

To report the effect of oral propranolol on intraocular pressure (IOP) in infants newly diagnosed with unilateral Sturge-Weber syndrome (SWS) glaucoma receiving no other treatment.

METHODS

This was a prospective, nonrandomized interventional case series. Four infants presenting with unilateral SWS glaucoma with no prior treatment were treated with oral propranolol at a dose of 2 mg/kg and followed thereafter.

RESULTS

Propranolol had a temporary IOP-lowering effect in 3 of 4 children after 1 week of treatment. This effect diminished thereafter and 3 of 4 children required additional medical or surgical treatment.

CONCLUSIONS

Oral propranolol has a temporary effect on IOP in SWS glaucoma and is not effective as a single treatment in this syndrome, yet can serve to delay surgical treatment for a short period of time. In one case, the glaucoma was well-controlled on this medication.

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.

Comparison of intralesional corticosteroid and propranolol treatment of periorbital infantile hemangiomas: an outcome study of 61 cases

PURPOSE

To compare intralesional corticosteroid (IC) injections with oral propranolol in children with periorbital infantile hemangioma (IH).

METHODS

Children were diagnosed with IH and treated with IC (n = 29) or propranolol (n = 14). In cases in which no further improvement was seen, treatment was stopped and the outcome measured. Type, duration, and complications of treatment and supportive or additional therapies were scored, along with outcomes of visual measurements, at the start and end of therapy.

RESULTS

Twenty-one of the 29 children (72%) treated with IC injections were given a second injection and 16 (55%) were given more than two. Median duration of IC therapy was 15.9 months (interquartile range (IQR) 10.28), compared with 6.5 months (IQR 4.87) for propranolol (p&lt;0.001). The complications reported after IC injections were bleeding (n = 9) and ulceration (n = 7). No complications were noted in the propranolol group. Additional therapy consisting of oral prednisolone therapy was applied in one child from the steroid-treated group. The levels of amblyopia and the median absolute improvement did not significantly differ between the groups.

CONCLUSIONS

The IC injections and oral propranolol medication equally improved amblyopia in children with IH of the periorbital and cheek region; however, propranolol was associated with fewer complications and additional or supportive treatment was not indicated. We prefer oral propranolol medication over IC injections in cases in which IH threatens to hamper visual acuity.

Diagnosis and management of infantile hemangiomas

Propranolol has replaced corticosteroids as preferred first-line therapy for the management of infantile hemangiomas (IH). The topical β-blocker timolol is now an alternative to oral propranolol and watchful waiting for smaller IH. Research in the last decade has provided evidence-based data about natural history, epidemiology, and syndromes associated with IH. The most pressing issue for the clinician treating children with IH is to understand current data to develop an individualized risk stratification for each patient and determine the likelihood of complications and need for treatment. This article emphasizes the nuances of complicated clinical presentations and current treatment recommendations.

Haemangioma: clinical course, complications and management

Despite their high incidence, most infantile haemangiomas (IH) do not require treatment as they regress spontaneously and most do not leave significant sequelae. For the subset of haemangiomas that require treatment, indications for intervention can be divided into three main categories: ulceration, disfigurement and impairment of function or vital structures. In addition, certain IH have a risk of associated structural anomalies. Given the wide heterogeneity of haemangiomas, deciding which haemangiomas need intervention and when to intervene requires a detailed knowledge of natural history and clinical indicators of increased risk.

Beta-blockers for the treatment of problematic hemangiomas

OBJECTIVE

To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas.

METHODS

A retrospective review of patients with hemangiomas presenting to the Alberta Children's Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy.

RESULTS

Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%).

CONCLUSIONS

Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.

Propranolol therapy for infantile hemangioma

CONTEXT

There has been widespread interest surrounding the use of beta-blockers (i.e. propranolol, timolol, nadolol, acebutolol) in the treatment of infantile hemangiomas (IH).

OBJECTIVE

To review literature evaluating treatment of IH with propranolol.

EVIDENCE ACQUISITION

We conducted a literature search on PubMed and investigated for case reports, case series, and controlled trials by using search terms including hemangioma and propranolol.

RESULTS

Data suggest that beta-blockers are efficacious in cutaneous, orbital, subglottic, and hepatic hemangiomas and assist in the resolution of ulcerated hemangiomas. Improvement has also been documented in children with PHACE syndrome. Propranolol produces favorable results in children who do not respond to steroids and with no long-term adverse effects. Propranolol should be administered with caution due to rare but serious side effects including hypoglycemia, wheezing, hypotension, and bradycardia. Additionally, recurrence of lesions following the cessation of treatment has been documented.

CONCLUSIONS

Although large-scale randomized controlled trials must be conducted in order to further evaluate the safety and the possible role of propranolol in the treatment of IH, the reviewed literature suggests that propranolol carries promise as a potential replacement for corticosteroids as first-line therapy or as a part of a multimodal approach.

Propranolol for the treatment of infantile haemangiomas: our experience with 44 patients

Propranolol is an effective, safe treatment for complicated infantile haemangiomas (IH). We evaluated all patients (n = 44) with IH treated with propranolol in our department. Of the 44 patients who were begun on propranolol therapy, 26 patients have completed the treatment to date and all had a good response. The mean duration of treatment was 45.7 weeks. Four patients developed rebound growth of their IH, which responded to the reintroduction of propranolol. Two patients with PHACES (posterior fossa malformations, haemangiomas, arterial anomalies, coarctation of the aorta/cardiac abnormalities, eye anomalies and sternal defects/supraumbilical raphe) syndrome were treated with lower than standard doses, because of concern about possible cerebrovascular compromise. Adverse effects were minor in most patients. Three patients discontinued propranolol because of vomiting, wheeze, and hypoglycaemia, respectively. Our duration of treatment was longer than that of other series, and may be due to our group having higher rates of hypotension, recorded in 27.3% of patients, precluding an increase in propranolol dose. Our experience supports that propranolol is an effective first-line agent for complicated IH.

Approach to the patient with an infantile hemangioma

Infantile hemangioma is the most common soft tissue tumor of childhood. Despite its frequency, it has only been in the last decade that these lesions have been better characterized and become the subject of significant clinical and translational research. Although most infantile hemangiomas are uncomplicated and do not require intervention, they can be a significant source of parental distress, cosmetic disfigurement, and morbidity. The wide spectrum of disease in the morphology of these lesions and in their behavior has made it difficult to predict the need for treatment and has made it challenging to establish a standardized approach to management.