What is the recommended treatment for hemangioma?

Treatment of Hemangiomas

Oral propranolol is the first-line treatment for infantile hemangiomas requiring systemic therapy, with a recommended dose of 2-3 mg/kg/day. 1

Risk Stratification and Assessment

Before initiating treatment, hemangiomas should be classified according to risk:

• High-risk hemangiomas require prompt evaluation and treatment if they present with:

  • Life-threatening complications
  • Functional impairment or ulceration
  • Structural anomalies (PHACE syndrome or LUMBAR syndrome)
  • Risk of permanent disfigurement 1

• Specific concerning locations include:

  • Periocular (can cause astigmatism, amblyopia)
  • Airway (may present with stridor)
  • Large facial hemangiomas
  • Lip and perineal areas (high risk of ulceration)
  • Hepatic hemangiomas 2

Treatment Algorithm

1. Observation

• Appropriate for small, innocuous hemangiomas without functional impairment
• Most hemangiomas follow a predictable pattern with growth stopping by 5 months and involution by 4 years 2
• Note that up to 70% leave residual skin changes even with involution 2

2. Systemic Therapy

First-line: Oral Propranolol

• Dosage: 2-3 mg/kg/day divided into 2-3 doses 1
• Duration: Minimum 6 months, often until 12 months of age 2
• Administration: Give with or after feeding; hold doses during times of diminished oral intake or vomiting 1
• Monitoring:
  • Initial cardiovascular monitoring every hour for first two hours
  • Repeated monitoring with dosage increases >0.5 mg/kg/day 1
  • Educate caregivers about potential adverse effects (sleep disturbances, bronchial irritation, bradycardia, hypotension) 1

Special considerations for propranolol:

• For patients with PHACE syndrome: Brain MRI/MRA should be done before starting full dose; initial dose 0.5 mg/kg/day 1
• For preterm/low weight infants: More cautious dosing schedule 1
• Caution in infants <5 weeks of age or postconceptional age <48 weeks 1

Second-line: Corticosteroids

• Consider if propranolol is contraindicated or ineffective
• Oral prednisolone/prednisone: 2-3 mg/kg/day as a single morning dose 1
• Most effective when initiated during proliferative phase 1

3. Topical Therapy

• Topical timolol maleate: Effective for thin and/or superficial hemangiomas 1
• Intralesional steroid injections: Consider for focal, bulky hemangiomas during proliferation or in critical locations (e.g., lip) 1

4. Surgical Management

• Generally delayed until after infancy to allow for involution 2
• Consider for:
  • Residual deformities after involution
  • Specific anatomic locations with functional concerns
  • Cases where the resulting scar would be similar to that after involution 1

5. Laser Therapy

• Useful for:
  • Early non-proliferating superficial lesions
  • Treating ulceration
  • Managing residual telangiectasia after involution 2

Treatment Efficacy

Propranolol has demonstrated superior efficacy compared to other treatments:

• 95% expected clearance with propranolol vs. 43% with oral steroids 1
• Significant regression typically observed within 2-4 weeks of starting propranolol 3, 4
• Response rates of 98.97% reported in randomized controlled trials 1

Common Pitfalls to Avoid

1. Delayed referral during critical growth phase (1-3 months) for high-risk hemangiomas 2
2. Assuming all lesions will resolve without sequelae - up to 70% leave permanent skin changes 2
3. Stopping treatment too early - rebound growth occurs in approximately 20% of cases when propranolol is discontinued prematurely 5
4. Inadequate monitoring for potential adverse effects of propranolol, especially hypoglycemia, bradycardia, and hypotension 1
5. Failure to recognize PHACE syndrome in patients with large facial hemangiomas, which requires modified treatment protocols 1

Remember that early intervention is critical for high-risk hemangiomas, as treatment during the proliferative phase (1-3 months of age) yields the best outcomes for preventing complications and permanent disfigurement.