Infantile Hemangiomas

University of California, San Francisco, CA and The Hospital for Sick Children, Toronto, ON

Birthmarks and Vascular Anomalies Center
and Division of Pediatric Dermatology, Benioff
Children’s Hospital, University of California, San
Francisco, CA

Infantile hemangiomas (IH) are among the most common vascular lesions of infancy. The incidence rate of infantile hemangiomas is approximately 4.5%, with virtually all IH presenting before the age of 3 months.¹ Various hypotheses have been proposed regarding their pathogenesis. These include placental embolization, somatic mutation of an endothelial type cell, stimulation of endothelial progenitor cells by hypoxia and mediation of growth by aberrant growth factors (ie, VEGF).² Risk factors include female sex, Caucasian race, prematurity, low birth weight, and multiple gestations. Maternal risk factors include advanced maternal age, placenta previa, and pre-eclampsia.³

The natural history of infantile hemangiomas has been well characterized, most typically with early proliferation followed by gradual involution. Not all IH require treatment as most resolve without significant sequelae, but a significant minority require active intervention. Indications for treatment include ulceration, potential for permanent disfigurement and functional compromise. The challenge in treating IH is to identify which are likely to cause long-term complications or sequelae and to intervene before permanent damage has been done. An approach to risk stratification can help in decision making regarding which IH can be left to involute on their own and which require active treatment (Table 1).⁴

The management of IH has been revolutionized by the serendipitous discovery by Léauté-Labrèze et al of the dramatic responses of infantile hemangiomas to beta blockers. The focus of our discussion of the various treatment options for IH emphasizes the approach to management in the “post-propranolol era” beginning in 2008 when this treatment option became available. A key management of therapy is timing. Many hemangiomas have reached their maximum growth very early, by 5 to 7 weeks of age. Most have completed or nearly completed growth by 3 months of age. For those that need treatment, “the sooner the better” to prevent complications or permanent scarring. Using knowledge of growth characteristics, the optimal time for referral for consideration of treatment is 4 weeks of age⁵!

Topical and local therapies are an appropriate choice for small, localized and relatively superficial IH (eg, low to moderate- risk category). Timolol maleate, a topical beta blocker, is gaining popularity in the treatment of superficial hemangiomas. We typically use the gel forming solution (0.5%).⁴ Timolol is FDA-approved for the treatment of glaucoma in infants. It is not approved for IH but there are hundreds of reports (in case series and case reports) of its use with largely favorable reports in pre-selected patients (where topical therapy might make a difference). It works more slowly than oral propranolol, with benefits often visible in a few weeks and continued improvement for several months. Theoretical side effects are similar to oral beta blockers, but have rarely been reported.⁴ Treatment should be limited to 1 drop BID to TID in order to minimize the risk of systemic absorption, especially on mucosal or ulcerated surfaces.⁶

Intralesional triamcinolone (TAC) is helpful in the treatment of certain IH, particularly small to medium-sized facial IH (eg, lip