Original article
Propranolol, a very promising treatment for ulceration in infantile hemangiomas: A study of 20 cases with matched historical controls

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Background

Ulceration is a common but poorly understood complication of infantile hemangiomas (IH) that is difficult to control.

Objective

To investigate the possible role of monotherapy with propranolol for ulcerating IH.

Methods

Propranolol was given to 20 patients with IH, who suffered from ulceration at the start of treatment (mean age at onset of treatment, 3.5 months; standard error of the mean: 0.4). After cardiac screening, propranolol was administered in a progressive schedule to 2 to 2.5 mg/kg per day, divided in 3 doses. Blood pressure, heart rate, and fasting glucose levels were monitored during the first 3 days in hospital and, in the absence of complications, treatment was continued at home until the age of approximately 1 year. The 20 propranolol-treated patients were matched to patients from a historical control group, seen before the ‘propranolol era’. These matches were randomly made by using clinical pictures based on type, location and size of the IH, extent of ulceration, and age at the start of ulceration.

Results

The time to complete healing from the onset of ulceration was significantly shorter for the propranolol-treated patients, compared with the control group (8.7 vs 22.4 weeks; t test: P < .015). In the propranolol group, a tendency to shorter ulceration duration was seen in patients starting propranolol at an earlier stage of disease.

Limitations

The study was limited by the partially retrospective design and the small number of patients.

Conclusion

Propranolol reduces the duration of ulceration in IH and seems to be more effective when started in an early phase. We propose propranolol as the treatment of first choice for ulcerating IH.

Introduction

Capsule Summary

  • Ulceration is a common complication of infantile hemangiomas and can be difficult to manage.

  • In this study of 20 patients, treatment with propranolol significantly shortened the ulceration time when compared with a group of matched historical controls.

  • It is possible that early administration of propranolol in the proliferation phase may prevent ulceration by limiting expansile growth of the hemangioma.

Infantile hemangiomas (IH) occur in approximately 10% to 12% of children younger than 1 year of age. The most common complication is ulceration, possibly affecting 5% to 13% of children with IH.1, 2 Ulceration is nearly always painful, and this leads to problems with eating and sleeping. There may also be bleeding and infection requiring treatment with oral antibiotics. Finally, ulceration heals with scarring, leading to functional problems and cosmetic disfigurement.3, 4, 5, 6 There is no uniform approach to treatment in the literature. In addition to all kinds of wound dressings, topical or oral antibiotics and pain management, treatment with oral corticosteroids, vincristine, interferon, flashlamp pulsed dye laser therapy, and surgical options have been described, often with disappointing results.1, 5, 7

Propranolol was recently introduced as a promising treatment for complicated IH.8 There have been several case-reports of propranolol therapy for ulcerating IH, but no comparative studies have been published.8, 9, 10 In our study, the role of this nonselective beta-blocker was explored by treating 20 patients with an ulcerating IH in the proliferation phase and comparing this patient group with similar historical controls.

Section snippets

Patients

An observational analysis was performed of IH patients treated with propranolol at the Radboud University Medical Centre Nijmegen (UMCN), the Netherlands, from October 2008 to March 2010. The medical records and photo-documentation of 56 infants were reviewed and all patients with ulceration were selected. Twenty patients suffered from ulceration at the start of the treatment (mean age at onset of treatment: 3.5 months, standard error of the mean [SEM] 0.4). Ulceration was not always the main

Patient characteristics

The 20 patients (Table I) with an ulcerating IH had a total of 78 IH, with an average number of 3.9 IH per patient (SEM 1.7).

Of this group, 16 (80%) were girls. The mean gestational age was 36.8 weeks (SEM 0.7). The mean birth weight was 3017 grams (SEM 195).

Nine patients (45%) were born prematurely (before 37 weeks’ gestation), one with extreme prematurity (gestational age 30.7 weeks).

The anatomic location of the ulcerating IH was as follows: 14 (70%) in the head and neck region, 1 on the

Discussion

A review of the literature reveals no evidence-based or uniformly accepted treatment plan for ulcerating IH. This is in part because of the unclear pathogenesis of the ulceration but also to the variable course of ulceration and involution of IH.6 The generally accepted triad for treatment of ulcerating IH is (1) wound care, (2) topical or oral antibiotics, and (3) adequate pain management. In addition, various therapeutic agents aimed at promoting involution of the IH have been used (eg,

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Funding sources: None.

Conflicts of interest: None declared.

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