This article is more than 5 years old. Information may no longer be current.
Expert: Propranolol is gold standard in infantile hemangiomas
Click Here to Manage Email Alerts
The common historical approach of “wait and see” for infantile hemangiomas can lead to bad outcomes, according to Lawrence A. Schachner, MD, a dermatologist and pediatrician.
“It’s an important subject because there’s been some sea changes,” Schachner said during the webinar, What Pediatricians Need to Know About Infantile Hemangiomas. “For many years, we used systemic steroids for hemangiomas. In recent years, we have a new gold standard, which is propranolol.”
Infantile hemangiomas can affect up to 5% of all newborns, according to Schachner, who is professor and chair of the department of dermatology, professor of pediatrics and co-director of the division of pediatric dermatology at University of Miami Miller School of Medicine.
Hemangiomas are more common in girls, Caucasians, and newborns who have a low birth weight or are preterm.
Any hemangioma that blocks a vital function, such as vision, breathing, swallowing, defecation or urination, or causes spinal issues is emergent and severe, he said.
It is important to have a relationship with a hemangioma specialist, who may be a pediatrician, especially in areas without a pediatric dermatologist, Schachner added.
“It’s thought that in utero, circulating endothelial progenitor cells will migrate to areas with conditions of hypoxia and developmental field disturbances, and in that way, we will start getting increased production of endothelial and vascular tissues, which seems to be mediated by several factors like VEGF, insulin-like growth-factor and others,” Schachner said.
Most hemangiomas are not present at birth but appear within the first few days of life.
“It’s thought that if you start treating at 1 month of age and no later than 3 months, you’ll get a much better outcome,” he said. “That is a critical window of opportunity for the treatment of choice, which is systemic propranolol.”
The most rapid growth can occur at 1 to 3 months of age. Most reach 80% of growth by 3 months of age and finish growing by 5 months.
Some newborns have a precursor, a cutaneous mark such as a patch of telangiectasias with surrounding pallor, Schachner said.
Hemangiomas can be classified as localized or focal, segmental or multifocal. Segmental hemangiomas are large at more than 5 cm and cover a specific area of the skin, such as the face or chest. Lumbar hemangiomas occur on the lower body. In neonatal hemangiomatosis, there are at least five hemangiomas present.
Schachner urged treating a hemangioma right away if it:
- has life-threatening and disfigurement potential;
- compromises a vital bodily function;
- is segmental;
- is painful;
- is bleeding or ulcerated;
- has a significant cosmetic impact; or
- is infected.
An important goal before treatment is to educate the family about the natural course and discuss the potential complications and treatment indications.
“Topical beta-blockers have proved useful in very small lesions,” he said. “But for large, deep hemangiomas, we want to use a systemic beta-blocker.”
Hemangeol (propranolol hydrochloride, Pierre Fabre) includes a scale of dosage recommended for a specific patient’s weight.
Schachner recommended propranolol dosing of ±1 mg/kg per day in two divided doses, then increasing to ±2 mg/kg per day in the second week, given in two divided doses, and increasing to ±3 mg/kg for the third week.
“I find that if you extend treatment to 12 months, you get less rebound when you stop,” he said. “Ten percent to 25% of kids rebound if [treatment is] maintained for 6 months, and you get a much smaller number if it’s maintained for 12 months.”
Sleep disturbances have been a surprising finding with treatment, he said, recommending administration earlier in the day and using a reduced dose at night if sleep disturbances occur. – by Abigail Sutton
Reference:
Schachner LA. What pediatricians need to know about infantile hemangiomas webinar. Nov. 5, 2019.
Disclosure: Schachner reports he has served on the advisory board for Pierre Faber.