What are the characteristics and treatment options for infantile hemangioma?

From the Guidelines

Infantile hemangiomas that are potentially problematic due to their size or location should be treated with oral propranolol at a dose of 2 to 3 mg/kg per day, as this has been shown to be effective in reducing the risk of complications and improving outcomes 1. The characteristics of infantile hemangiomas include their appearance within the first few weeks of life, rapid growth for several months, and gradual regression over years. Most hemangiomas are small and innocuous, but a significant minority can cause permanent scarring and disfigurement, or lead to functional impairment, ulceration, or bleeding.

Key Characteristics of Infantile Hemangiomas

• Occur in up to 5% of infants
• Typically appear within the first few weeks of life
• Grow rapidly for several months, with the most significant growth occurring between 1 and 3 months of age
• Gradually regress over years, but may leave behind permanent skin changes
• Can cause functional impairment, ulceration, bleeding, or significant disfigurement if left untreated

Treatment Options

• Oral propranolol: first-line treatment for problematic hemangiomas, typically started at 2 to 3 mg/kg per day and continued for at least 6 months 1
• Topical timolol: may be used to treat select small, thin, superficial hemangiomas
• Surgery and/or laser treatment: may be considered for the treatment of residual skin changes after involution, or for hemangiomas that are not responsive to medical treatment It is essential to note that early intervention and referral to a specialist are crucial for infants with potentially problematic hemangiomas, ideally by 1 month of age 1. Parents should be counseled that treatment aims to prevent complications rather than completely eliminate the lesion, and that some residual skin changes may persist even after successful treatment. Regular follow-up is necessary to monitor response and adjust treatment as needed.

Important Considerations

• Cardiac evaluation and monitoring of heart rate and blood pressure are necessary before starting propranolol
• Common side effects of propranolol include sleep disturbances, cool extremities, and gastrointestinal upset
• Early referral to a specialist is recommended for hemangiomas in high-risk locations, such as the face, airway, or genital area 1

From the Research

Characteristics of Infantile Hemangioma

• Infantile hemangioma (IH) is the most common vascular tumor of infancy, affecting up to 10% of all infants 2
• IH is characterized by an early rapid proliferation followed by progressive involution 3
• The pathogenesis of IH is still poorly understood, but hypoxia is thought to play a key role, and GLUT1, IGF2, and HIF-1-? are thought to be important mediators 2
• IH often appears in the first few weeks of life as areas of pallor, followed by telangiectatic or faint red patches, and then grows rapidly in the first 3 to 6 months of life 4
• Superficial lesions are bright red, protuberant, bosselated, or with a smooth surface, and sharply demarcated, while deep lesions are bluish and dome-shaped 4

Treatment Options for Infantile Hemangioma

• The majority of IHs do not require active treatment, but only active observation 5, 4
• Treatment options include oral propranolol, topical timolol, and oral corticosteroids 3, 4, 6
• Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration, interference with vital structures, life- or function-threatening complications, and significant disfigurement 4
• Oral propranolol is currently the mainstay of treatment and the treatment of choice for high-risk and complicated IHs 3, 4, 6
• Topical timolol may be considered for superficial IHs that need to be treated and for complicated IHs in patients at risk for severe adverse events from oral administration of propranolol 4, 6
• Other therapeutic modalities, such as pulsed dye laser, and treatment with off-label drugs, such as itraconazole or sirolimus, may also be used 6

Management Approach

• IH should be managed with an individual, patient-centered approach 2
• 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 4
• The goals of treatment are preventing cosmetic disfiguration, psychosocial distress, and life-threatening complications 2