Standard Treatment for Hemangiomas
Oral propranolol is the first-line treatment for complicated infantile hemangiomas, typically administered at 2-3 mg/kg/day divided into 2-3 doses for at least 6 months. 1, 2
Classification and Natural History
Hemangiomas are classified into several types:
- Infantile hemangiomas (IH): Most common (affecting 5% of infants), appear before 4 weeks, complete most growth by 5 months
- Congenital hemangiomas: Present at birth (RICH and NICH variants)
- Vascular malformations: Structural anomalies present at birth but may become apparent later 1
The natural course of infantile hemangiomas includes:
- Proliferative phase (up to 12 months)
- Involution phase (begins between 6-12 months)
- Majority of regression occurs before 4 years of age 1
Treatment Decision Algorithm
1. Observation (No Treatment)
- Most infantile hemangiomas (approximately 90%) do not require therapy and regress spontaneously 2, 3
- Close follow-up is crucial in the first weeks of life, as 80% reach their final size by 3 months 2
2. Indications for Active Treatment
Treatment is indicated for:
- Life-threatening hemangiomas (causing heart failure or respiratory distress)
- Functional risks (visual obstruction, amblyopia, feeding difficulties)
- Ulceration
- Severe anatomic distortion, especially on the face
- Hemangiomas in critical locations (periorbital, airway) 1, 2
3. Treatment Options
First-Line Treatment
- Oral propranolol: 2-3 mg/kg/day divided into 2-3 doses for at least 6 months 1, 2
- Should be initiated as early as possible to avoid complications
- Rapid shrinkage is typically observed
- Higher efficacy in patients with elevated pretreatment serum bFGF (>37.07 pg/mL) and VEGF levels 4
Alternative Treatments (when propranolol is contraindicated or ineffective)
- Corticosteroids: Oral prednisolone/prednisone at 2-3 mg/kg/day as a morning dose 1
- Topical timolol 0.5% gel: For superficial hemangiomas 1
- Intralesional steroid injections 1, 5
- Laser therapy: Particularly for residual lesions after medical therapy 1
Surgical Options
Indicated for:
- Failure to respond to medical therapy
- Significant residual tissue after medical treatment
- Bleeding, ulceration, or functional impairment
- Cosmetic disfigurement 1
For hepatic hemangiomas:
- Asymptomatic lesions <5 cm: Observation
- Lesions ≥5 cm or multiple lesions: Surgical options (enucleation or formal liver resection)
- Bland embolization as an alternative to surgery for larger lesions 1
Monitoring and Follow-up
- Regular follow-up every 3-6 months
- Close monitoring during rapid growth phase (5-7 weeks of age)
- Documentation of changes with photographs when possible
- Long-term follow-up may be needed as up to 70% of infantile hemangiomas leave permanent skin changes 1
Special Considerations
- Prophylactic treatment with propranolol should be considered for high-risk hemangiomas before bleeding occurs
- Hemangiomas in vulnerable locations should be protected from trauma
- For ulcerated hemangiomas: Clean with mild antiseptic solution, apply non-adherent dressing, consider petroleum jelly-impregnated gauze 1
- Infants with multiple cutaneous lesions should undergo screening ultrasound
- Monitor thyroid function in cases of hepatic hemangiomas 1
Treatment Efficacy Biomarkers
Recent research suggests that serum cytokines may help predict treatment response:
- Patients with higher pretreatment bFGF and VEGF levels show better response to propranolol
- Decreases in MMP-2, bFGF, VEGF-α, and MCP-1 are associated with hemangioma regression during propranolol treatment 4