From the Guidelines
No, topical propranolol is not indicated for all types of hemangiomas. The most recent and highest quality study, published in 2019 in the journal Pediatrics 1, suggests that oral propranolol is the first-line treatment for problematic infantile hemangiomas, typically prescribed at 2-3 mg/kg/day divided into 2-3 doses for 6-12 months.
Key Considerations
- Topical propranolol (1-3% formulation) has limited efficacy and is generally only considered for very superficial or small hemangiomas where systemic therapy is not warranted.
- It works best for thin, superficial lesions and has minimal effect on deep components of mixed hemangiomas.
- The topical route avoids systemic side effects like hypoglycemia, bradycardia, and hypotension that can occur with oral administration, but its penetration is insufficient for thicker or deeper lesions.
- Treatment decisions should be based on the hemangioma's location, size, depth, growth phase, and associated complications.
- Congenital hemangiomas and other vascular anomalies typically do not respond to propranolol therapy at all, further limiting the application of both topical and oral formulations.
Additional Guidance
According to the American Academy of Pediatrics report released in 2016 1, hemangiomas should be treated in the setting of a life-threatening condition, functional impairment, pain, or bleeding, and medical therapy includes oral propranolol, oral corticosteroids, and intralesional steroid injections. However, the most recent guideline from 2019 1 takes precedence, emphasizing the importance of early intervention and referral for potentially problematic IHs, and the use of oral propranolol as the drug of choice for systemic treatment.
Summary of Recommendations
- Oral propranolol is the first-line treatment for problematic infantile hemangiomas.
- Topical propranolol may be considered for very superficial or small hemangiomas.
- Treatment decisions should be individualized based on the hemangioma's characteristics and associated complications.
From the Research
Indications for Topical Propranolol
- Topical propranolol is indicated for the treatment of superficial infantile hemangiomas (IHs) 2, 3.
- It is particularly suitable for patients with small, superficial hemangiomas at risk of cosmetic sequelae, where the cosmetic or symptomatic impact does not warrant oral propranolol treatment 2.
- The use of topical propranolol may be considered in patients at risk of potential side effects from oral administration 4.
Efficacy and Safety
- Topical propranolol has been shown to be effective in treating superficial IHs, with a good or excellent response seen in 59% of lesions 2.
- The treatment is well tolerated, with no systemic adverse effects reported and minor local reactions seen in 1.3% of patients 2.
- Topical propranolol may be less effective than oral propranolol, but it is safer and can be used as an alternative for patients who are at risk of side effects from oral propranolol 4.
Comparison with Other Treatments
- Topical propranolol and topical timolol have been found to be as effective as oral propranolol in treating superficial IHs 5.
- Topical timolol has been found to be more effective than topical imiquimod, observation, and topical saline solutions in treating superficial IHs 5.
- Compared with oral propranolol, topical timolol is associated with fewer incidences of adverse effects 5.
Clinical Experience
- A literature review and 4 years of clinical experience have shown that topical propranolol cream is a safe and effective treatment for superficial IHs 3.
- The majority of hemangiomas treated with topical propranolol achieved a significant reduction in size, with 62.5% achieving an excellent response 3.