From the Guidelines
Beta blockers are indicated for infantile hemangiomas but not congenital hemangiomas because of fundamental differences in their natural history and pathophysiology. Infantile hemangiomas undergo a proliferative phase after birth that responds to beta blockers like propranolol, which inhibits angiogenesis, induces vasoconstriction, and triggers apoptosis of capillary endothelial cells 1. The standard treatment is oral propranolol at 2-3 mg/kg/day divided into two or three doses for 6-12 months, with treatment typically initiated during the proliferative phase (before 5 months of age) and continued until regression or at least 6 months of age.
Some key points to consider in the management of infantile hemangiomas include:
- Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs 1
- Topical timolol may be used to treat select small, thin, superficial IHs 1
- Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs 1
In contrast, congenital hemangiomas are fully formed at birth, do not have a proliferative phase postnatally, and have different cellular markers and vascular characteristics 1. They either rapidly involute (RICH), partially involute (PICH), or remain stable (NICH) without responding to beta blocker therapy. This distinction is crucial for appropriate management, as prescribing beta blockers for congenital hemangiomas would be ineffective and expose patients to unnecessary medication risks.
The use of propranolol in the treatment of infantile hemangiomas has been well established, with studies showing its safety and efficacy 1. The British Society for Paediatric Dermatology has also provided guidelines for the use of propranolol in the treatment of infantile hemangiomas, which include recommendations for dosing, treatment duration, and monitoring 1.
Alternative therapies, such as corticosteroids, may be considered if propranolol cannot be used or is not effective 1. However, the primary treatment for infantile hemangiomas remains beta blockers, and congenital hemangiomas should not be treated with beta blockers due to their distinct natural history and pathophysiology.
From the Research
Indications for Beta Blockers in Hemangiomas
- Beta blockers, specifically propranolol, have become the first-line treatment for infantile hemangiomas since 2008, as they have been shown to be effective in preventing the growth of these tumors 2, 3, 4.
- The use of beta blockers for congenital hemangiomas is not well established, and the current evidence primarily supports their use in infantile hemangiomas.
- Infantile hemangiomas are the most common tumor of infancy, and beta blockers have revolutionized their treatment, providing a safer and more effective alternative to previous therapeutic options 2, 3.
Differences between Infantile and Congenital Hemangiomas
- Infantile hemangiomas typically appear after birth, whereas congenital hemangiomas are present at birth.
- The pathogenesis of infantile hemangiomas is not fully understood, but maternal hypoxic stress and embolization of placental tissue are suggested to be critical components in their development 3.
- Congenital hemangiomas, on the other hand, may have a different underlying mechanism, which could explain why beta blockers are not typically indicated for their treatment.
Safety and Efficacy of Beta Blockers
- Propranolol has been shown to be safe and effective for the treatment of infantile hemangiomas, even in infants less than five weeks corrected age 5.
- The most common side effects of propranolol include sleep disturbance, irritability, and cool hands/feet, but serious adverse events are rare 5.
- Other beta blockers, such as atenolol and nadolol, may offer similar efficacy, but more research is needed to fully understand their role in the treatment of infantile hemangiomas 2, 6.