Will propranolol become the mainstay of treatment for symptomatic infantile hemangiomas (IH)?
Background: IH are the most common tumor of infancy, affecting four to 10 percent of infants. Spontaneous involution is the expected outcome, but nearly 10 percent cause symptoms warranting early therapy. Propranolol was serendipitously found to hasten IH involution, with fewer side effects than traditional corticosteroid therapy, in an index case and 10 additional cases reported in the New England Journal of Medicine (2008;358:2649-2651).
Study Design: Observational case series of 32 patients, including previously reported 11.
Setting: Children’s Hospital, Pellegrin Hospital and Saint Andre Hospital, Bordeaux, France; Purpan Hospital, Toulouse, France; Strasbourg Hospital, Strasbourg, France; Fort de France Hospital, Fort de France, France.
Synopsis: Propranolol (2 mg/kg/day) was given during the proliferative phase (n=27, mean 4.2 m) or plateau phase (n=5, mean 31 m) for a mean of six months. Softening and lightening of the hemangioma was immediately noted in all patients. Dyspnea, ocular opening and hemodynamics were the most common indications for starting therapy and improved within the first week. Ulcerations healed within two months. Ultrasound showed 40 percent regression in maximal thickness (n=11, 60 days). Corticosteroids were first used in 13 patients with minimal response and all were stopped within the first month of starting propranolol.
Adverse effects were rare. It is unclear whether vital signs were monitored for the first six or 24 hours; however, transient hypotension was only reported in one patient. Propranolol was stopped after three months in another patient due to wheezing. Therapy was concluded in 16 patients at the time of the report and had to be resumed in two patients with symptomatic regrowth.
Bottom Line: Propranolol appears to be an effective and well-tolerated as a first-line treatment for symptomatic IH. Prospective studies comparing efficacy and side effects with corticosteroids are needed.
Citation: Sans V, Dumas de la Roque E, Berge J, et al. Propranolol for severe infantile hemangiomas: Follow-up report. Pediatrics. 2009;124:e423-31.