Infantile Hemangiomas

and nasal tip IH) which are a bit too deep for timolol, but are well-localized enough such that propranolol may not be (at least initially) indicated.⁴ Triamcinolone acetonide at a concentration of 10 mg/ml can be injected every 3-4 weeks during the proliferative phase, taking care to evenly distribute the medication evenly throughout the target hemangioma. The dose should not exceed 1-2 mg/kg.⁴ Side effects include bleeding, atrophy and possibly systemic absorption. Couto et al recently published a retrospective study looking at the efficacy and safety of intralesional TAC in 100 patients. None of the patients had systemic absorption and skin atrophy was observed in only 2% of participants⁷.

Imiquimod 5% has been used in some centers as an alternative topical treatment. Qiu at al completed a retrospective study comparing timolol to imiquimod therapy. Although they had similar response rates and efficacy, there were more side effects recorded in the imiquimod group.⁸ Cryotherapy has been used by some practitioners but has lost favor in recent years.

In patients with identified high risk lesions, the goal is to begin systemic therapy before evidence of functional compromise or permanent disfigurement has developed. Lesions with aggressive growth, a high threat of functional impairment or sequelae and those not responding to local measures should be considered for systemic therapy.

Current first line systemic therapy is oral beta blockers for complicated infantile hemangiomas. Propranolol is the most commonly used formulation. It is a systemic non-selective beta blocker. A recent meta-analysis looked at 1264 patients enrolled in 41 studies. The response rate for propranolol was found to be 98%,⁶ showing better efficacy and less toxicity than steroids.⁴ The most common adverse events include sleep disturbance and cold extremities. Cardiovascular side effects (eg, hypotension or bradycardia) are surprisingly rare.⁶ The risk of hypoglycemia can be decreased by feeding frequently, giving the medication after feeding, and avoiding long periods without eating (eg, prolonged periods of sleep) in infants <6 months of age.⁴ In 2013, Martin et al published anticipatory guidance information that can be distributed to parents on propranolol initiation, outlining the side effects and monitoring required during therapy.⁹

While a consensus statement published in 2013 helped to standardize the initiation of propranolol across treatment centers,¹⁰ including the lack of need for hospitalization of older children and recommending a dose range of 1-3 mg/kg/d of propranolol divided TID, FDA approval of Hemangeol^® has led to slightly different recommendation. This product is FDA-approved for infants aged 5 weeks of age (adjusted for gestational age) and older with BID dosing and lack of need for hospitalization for initiation of therapy unless other medical morbidities exist. For outpatient initiation, heart rate and blood pressure should be monitored before treatment and at 1h and 2h post treatment following the initial dose and in any dose increase over 0.5 mg/