What is the best management approach for infantile hemangiomas (IH) and is propranolol (beta blocker) used to treat only skin hemangiomas or also systemic hemangiomas?

From the Guidelines

The best management approach for infantile hemangiomas (IH) is oral propranolol, which is considered first-line therapy for complicated hemangiomas requiring systemic treatment, as recommended by the American Academy of Pediatrics 1.

Key Points to Consider

• Propranolol is effective for both cutaneous (skin) hemangiomas and systemic/visceral hemangiomas, including those affecting internal organs like the liver.
• The standard dosing regimen is 2-3 mg/kg/day divided into two or three doses, typically continued for 6-12 months.
• Treatment should be initiated under medical supervision due to potential cardiovascular side effects.
• For uncomplicated, small hemangiomas without functional impairment, observation may be appropriate as many will spontaneously involute.
• Topical beta-blockers like timolol may be used for superficial, small lesions.

Important Considerations

• Before starting treatment, patients should undergo baseline cardiovascular assessment, including blood pressure, heart rate, and cardiac evaluation if indicated, as suggested by the British Society for Paediatric Dermatology 1.
• Blood glucose monitoring may be necessary, especially in infants, as propranolol can mask hypoglycemic symptoms.
• Treatment should be temporarily withheld during intercurrent illness, particularly if associated with reduced oral intake.
• The British Society for Paediatric Dermatology also recommends that treatment can be stopped at 1 year of age, and the majority of patients with IH do not need treatment beyond 17 months of age, and it is safe to stop propranolol abruptly at the end of therapy 1.

Classification and Management

• Infantile hemangiomas can be classified based on their location, size, and potential for complications.
• The management approach should be individualized based on the specific characteristics of the hemangioma and the patient's overall health.
• Propranolol has been shown to be effective in reducing the size and severity of infantile hemangiomas, and is considered a safe and well-tolerated treatment option, as reported in the American Family Physician 1.

From the Research

Classification of Infantile Hemangiomas

• Infantile hemangiomas are the most common vascular tumors of infancy, affecting up to 12% of infants by the first year of life 2.
• They are classified based on their depth and location, with superficial lesions being bright red and protuberant, and deep lesions being bluish and dome-shaped 2.

Best Management Approach

• A multidisciplinary approach including dermatologists, otolaryngologists, plastic surgeons, hematologists/oncologists, and interventional/diagnostic radiologists is crucial for appropriate management of children with complicated infantile hemangiomas 3.
• The majority of infantile hemangiomas require no treatment, but treatment options include oral propranolol, topical timolol, and oral corticosteroids 2.
• Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration, interference with vital structures, life- or function-threatening complications, and significant disfigurement 2.

Use of Propranolol

• Propranolol has become the first-line treatment for infantile hemangiomas, eclipsing systemic corticosteroids and radiologic intervention 3.
• Oral propranolol is the treatment of choice for high-risk and complicated infantile hemangiomas 2.
• Propranolol may be used to treat not only skin hemangiomas but also other systemic hemangiomas, as part of a multidisciplinary approach to manage complicated infantile hemangiomas 3.
• Combination therapy of oral propranolol and laser therapy, such as pulsed dye laser or Nd:YAG laser, can be used sequentially or in parallel to treat infantile hemangiomas safely and effectively 4, 5.

Treatment Outcomes

• Propranolol can induce earlier involution and redness reduction of infantile hemangiomas, but the optimal treatment duration is unknown and infantile hemangiomas sometimes recur after cessation of treatment 6.
• Combination therapy of propranolol and laser therapy can reduce treatment duration and sequelae incidence and severity 5.
• Patients with infantile hemangiomas who have taken oral propranolol should be followed up at least 6 months after cessation of treatment, especially for lesions on the cheek, and those with partial response to propranolol may require close attention in prolonged growth 6.