Propranolol Tried for Severe Hemangiomas

BALTIMORE — Propranolol for the treatment of severe infantile hemangiomas is getting some buzz in pediatric dermatology circles, and results from a new patient series support the interest.

Investigators at Johns Hopkins University treated 25 patients for a total 35 hemangiomas with propranolol. Dr. Katherine B. Puttgen reported interim results for 20 children—with a mean therapy duration of 3.7 months—at the Atlantic Dermatologic Conference. In all, 14 children (70%) who completed treatment had moderate or marked hemangioma improvement.

Interest in using the beta-blocker for the treatment of hemangiomas was piqued by a letter in the New England Journal of Medicine, in which French researchers reported that severe hemangiomas on 11 infants dramatically improved with propranolol (N. Engl. J. Med. 2008;358:2649–51). The letter “created a firestorm of activity and enthusiasm in the pediatric dermatology community,” said Dr. Puttgen, who is an assistant professor of pediatric dermatology at the Johns Hopkins University.

The mechanism of action for propranolol is unknown though “clearly there must be something vasoconstrictive going on in the hemangioma because within a couple of days of the initiation of therapy, the hemangiomas tend to become much softer … and more violaceous in color,” Dr. Puttgen said.

At Hopkins, pediatric cardiologists suggested admitting the infants for monitoring for 2–3 days because of the rapid dose escalation. The infants are started at a dose of 1 mg/kg per day, which is doubled 24 hours later. All of the infants get a baseline EKG. While the children are in the hospital, vital signs and blood glucose levels are measured 1 hour after each dose. Serial photographs are taken to measure change over time. After the infants are discharged, their blood pressure and heart rate should be checked at their pediatrician's office every 48 hours for the first week.

In the series, girls out-numbered boys 4:1. Most of the infants were white (20), 2 were black, 2 were Hispanic, and 1 was of Middle Eastern descent. Patients ranged in age from 28 days to 5 years, though most of the children were started on treatment at 2–4 months of age (mean 239 days, median 97 days).

Most of the patients (84%) had facial hemangiomas, most of which were focal (88%); 56% were of a mixed morphologic subtype. The most common complication was ulceration (32%). The biggest concern with propranolol is the risk for hypotension and low blood glucose in patients. One patient discontinued treatment due to hypotension.

None of the hemangiomas have worsened, Dr. Puttgen noted. Five patients had no or minimal change, two of whom were older. Three patients were considered to have moderate improvement, and 11 had marked improvement. Five infants were excluded because they are still on the treatment.

While many infants have impressive results, it is already clear that not all hemangiomas respond to propranolol, Dr. Puttgen noted.

Dr. Anthony J. Mancini, of Children's Memorial Hospital in Chicago, cautioned that the results are impressive but a number of questions need to be answered before propranolol becomes widely used for infantile hemangiomas.

Dr. Puttgen reported having no relevant financial conflicts of interest.

Despite 3 weeks of prednisolone, this infant's hemangioma remained severe on day 1 of propranolol therapy (left). Follow-up is shown 7 months later (right). Photos courtesy Dr. Katherine B. Puttgen

BALTIMORE — Propranolol for the treatment of severe infantile hemangiomas is getting some buzz in pediatric dermatology circles, and results from a new patient series support the interest.

Investigators at Johns Hopkins University treated 25 patients for a total 35 hemangiomas with propranolol. Dr. Katherine B. Puttgen reported interim results for 20 children—with a mean therapy duration of 3.7 months—at the Atlantic Dermatologic Conference. In all, 14 children (70%) who completed treatment had moderate or marked hemangioma improvement.

Interest in using the beta-blocker for the treatment of hemangiomas was piqued by a letter in the New England Journal of Medicine, in which French researchers reported that severe hemangiomas on 11 infants dramatically improved with propranolol (N. Engl. J. Med. 2008;358:2649–51). The letter “created a firestorm of activity and enthusiasm in the pediatric dermatology community,” said Dr. Puttgen, who is an assistant professor of pediatric dermatology at the Johns Hopkins University.

The mechanism of action for propranolol is unknown though “clearly there must be something vasoconstrictive going on in the hemangioma because within a couple of days of the initiation of therapy, the hemangiomas tend to become much softer … and more violaceous in color,” Dr. Puttgen said.

At Hopkins, pediatric cardiologists suggested admitting the infants for monitoring for 2–3 days because of the rapid dose escalation. The infants are started at a dose of 1 mg/kg per day, which is doubled 24 hours later. All of the infants get a baseline EKG. While the children are in the hospital, vital signs and blood glucose levels are measured 1 hour after each dose. Serial photographs are taken to measure change over time. After the infants are discharged, their blood pressure and heart rate should be checked at their pediatrician's office every 48 hours for the first week.

In the series, girls out-numbered boys 4:1. Most of the infants were white (20), 2 were black, 2 were Hispanic, and 1 was of Middle Eastern descent. Patients ranged in age from 28 days to 5 years, though most of the children were started on treatment at 2–4 months of age (mean 239 days, median 97 days).

Most of the patients (84%) had facial hemangiomas, most of which were focal (88%); 56% were of a mixed morphologic subtype. The most common complication was ulceration (32%). The biggest concern with propranolol is the risk for hypotension and low blood glucose in patients. One patient discontinued treatment due to hypotension.

None of the hemangiomas have worsened, Dr. Puttgen noted. Five patients had no or minimal change, two of whom were older. Three patients were considered to have moderate improvement, and 11 had marked improvement. Five infants were excluded because they are still on the treatment.

While many infants have impressive results, it is already clear that not all hemangiomas respond to propranolol, Dr. Puttgen noted.

Dr. Anthony J. Mancini, of Children's Memorial Hospital in Chicago, cautioned that the results are impressive but a number of questions need to be answered before propranolol becomes widely used for infantile hemangiomas.

Dr. Puttgen reported having no relevant financial conflicts of interest.

Despite 3 weeks of prednisolone, this infant's hemangioma remained severe on day 1 of propranolol therapy (left). Follow-up is shown 7 months later (right). Photos courtesy Dr. Katherine B. Puttgen

BALTIMORE — Propranolol for the treatment of severe infantile hemangiomas is getting some buzz in pediatric dermatology circles, and results from a new patient series support the interest.

Investigators at Johns Hopkins University treated 25 patients for a total 35 hemangiomas with propranolol. Dr. Katherine B. Puttgen reported interim results for 20 children—with a mean therapy duration of 3.7 months—at the Atlantic Dermatologic Conference. In all, 14 children (70%) who completed treatment had moderate or marked hemangioma improvement.

Interest in using the beta-blocker for the treatment of hemangiomas was piqued by a letter in the New England Journal of Medicine, in which French researchers reported that severe hemangiomas on 11 infants dramatically improved with propranolol (N. Engl. J. Med. 2008;358:2649–51). The letter “created a firestorm of activity and enthusiasm in the pediatric dermatology community,” said Dr. Puttgen, who is an assistant professor of pediatric dermatology at the Johns Hopkins University.

The mechanism of action for propranolol is unknown though “clearly there must be something vasoconstrictive going on in the hemangioma because within a couple of days of the initiation of therapy, the hemangiomas tend to become much softer … and more violaceous in color,” Dr. Puttgen said.

At Hopkins, pediatric cardiologists suggested admitting the infants for monitoring for 2–3 days because of the rapid dose escalation. The infants are started at a dose of 1 mg/kg per day, which is doubled 24 hours later. All of the infants get a baseline EKG. While the children are in the hospital, vital signs and blood glucose levels are measured 1 hour after each dose. Serial photographs are taken to measure change over time. After the infants are discharged, their blood pressure and heart rate should be checked at their pediatrician's office every 48 hours for the first week.

In the series, girls out-numbered boys 4:1. Most of the infants were white (20), 2 were black, 2 were Hispanic, and 1 was of Middle Eastern descent. Patients ranged in age from 28 days to 5 years, though most of the children were started on treatment at 2–4 months of age (mean 239 days, median 97 days).

Most of the patients (84%) had facial hemangiomas, most of which were focal (88%); 56% were of a mixed morphologic subtype. The most common complication was ulceration (32%). The biggest concern with propranolol is the risk for hypotension and low blood glucose in patients. One patient discontinued treatment due to hypotension.

None of the hemangiomas have worsened, Dr. Puttgen noted. Five patients had no or minimal change, two of whom were older. Three patients were considered to have moderate improvement, and 11 had marked improvement. Five infants were excluded because they are still on the treatment.

While many infants have impressive results, it is already clear that not all hemangiomas respond to propranolol, Dr. Puttgen noted.

Dr. Anthony J. Mancini, of Children's Memorial Hospital in Chicago, cautioned that the results are impressive but a number of questions need to be answered before propranolol becomes widely used for infantile hemangiomas.

Dr. Puttgen reported having no relevant financial conflicts of interest.

Despite 3 weeks of prednisolone, this infant's hemangioma remained severe on day 1 of propranolol therapy (left). Follow-up is shown 7 months later (right). Photos courtesy Dr. Katherine B. Puttgen