COMMENTARY

Pretty Baby: Propranolol for Noncritical Infantile Hemangiomas?

Graeme M. Lipper, MD

Disclosures

April 05, 2017

Risk Factors for Degree and Type of Sequelae After Involution of Untreated Hemangiomas of Infancy

Baselga E, Roe E, Coulie J, et al
JAMA Dermatol. 2016;152:1239-1243

Background

The benign vascular neoplasms of infantile hemangiomas (IHs) are the most common soft tissue tumors of infancy, with one recent study showing a growing prevalence over the past 3 decades, especially in premature infants, with an incidence rate of 1.64 per 100 person-years.[1] Although up to 50% of IHs involute within the first 5 years of life, lesions in critical anatomic areas can be life-threatening (eg, subglottic hemangiomas, hepatic hemangiomas), result in permanent functional impairment (eg, periocular IH), cause ulceration and pain, or leave cosmetically disfiguring residue.[2] These more complicated IH cases require aggressive and early intervention.

Fortunately, the oral beta blocker propranolol has revolutionized IH treatment over the past decade and has replaced systemic corticosteroids as the treatment of choice for complicated IH. Up to 98% of IH cases respond to propranolol therapy, with complete regression seen in 60% of cases after an average of 6 months of therapy.[3,4,5] These results are far superior to those seen with oral corticosteroids and come with a dramatically lower risk for adverse effects.[6,7]

Discussion

Because propranolol is so effective at inducing IH regression and has such a favorable safety profile, must treatment be limited only to hemangiomas that pose a functional or health risk? What about undesirable cosmetic sequelae such as atrophic scarring, residual telangiectasia, or soft tissue hypertrophy? If we could use hemangioma characteristics to predict more severe cosmetic sequelae, this might help to identify which "noncritical" IHs still warrant early intervention.

Study Summary

Inspired by this proposition, Baselga and colleagues performed a retrospective cohort study of images from 184 patients with untreated IH, followed for a mean of 4 years. In this group, the average age of IH involution was 3.4 years. Postinvolution photos showed significant cosmetic sequelae in a surprisingly high 55% of cases. These were divided into the following most common residuum:

  1. Telangiectasia (seen in 84.3%);

  2. Fibrofatty tissue (47.1%, seen most commonly in deep and combined IH); and

  3. Anetodermic skin (32.6%, most strongly associated with IH with a "cobblestoned" surface appearance).

In the most important part of this study, investigators identified the IH features most predictive of poorer cosmetic outcomes:

  1. Combined IH (mixed hemangiomas with both superficial and deep components)

  2. IH with a "step" or abrupt border

  3. IH in which the superficial component had a "cobblestoned" surface

  4. IH on the tip of the nose and lips (72% and 53% left significant to severe sequelae, respectively); and

  5. Pedunculated IH left fibrofatty tissue residuum (but this observation was limited by the small number of examples).

Viewpoint

This study is a gem with valuable, practical information to be mined. By cataloguing which clinical characteristics of IH are predictive of poor cosmetic outcomes, Baselga and colleagues have added a new dimension to IH therapy.

Oral propranolol has proven to be a safe, highly effective treatment for IH. Adverse effects are rare, with a recent meta-analysis (n=1264 patients) showing the most common adverse events associated with propranolol (mean dose, 2.1 mg/kg/day) to be sleep disruption and acrocyanosis; in this 4-year review,[5] significant adverse events were uncommon (symptomatic hypotension, n=5; hypoglycemia, n=4; symptomatic bradycardia, n=1).

In this context, parents of children with IH should be counseled on potential adverse cosmetic sequelae, guided by the clinical characteristics identified above. In some cases, the greater likelihood of cosmetic disfigurement may well justify more aggressive early intervention with propranolol, even if the hemangiomas pose no physical health risk.

Abstract

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