Propranolol versus corticosteroids in the treatment of infantile hemangioma: a systematic review and meta-analysis. Plast Reconstr Surg. 2013;131:601-613. [PMID: 23142941 DOI: 10.1097/prs.0b013e31827c6fab]

PHACES syndrome: Diode laser photocoagulation of intraoral hemangiomas in six young patients

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This study well defines the oral clinical aspects of PHACES oral hemangiomas, poorly noticed in current English literature, and their laser therapy.

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Diode laser photocoagulation techniques have been proved to be very effective and minimally invasive surgical treatment for IH in syndromic patient considering the presence of numerous lesions and the necessity of several interventions.

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This study shows the two main laser technique used for the treatment of oral hemangiomas highlighting the differences between these ones and their main recommendations.

Introduction

The acronym PHACES describes the association of posterior fossa malformations, facial hemangiomas, arterial anomalies (cardiovascular or cerebrovascular), coarctation of the aorta and cardiac defects, eye abnormalities, and sternal or ventral defects. In this study we report on 6 patients affected by the PHACES syndrome and showing 34 intraoral hemangiomas (IH), treated by diode laser photocoagulation (DLP).

Case presentation

IH appeared as red-bluish soft masses, smooth or lobulated, from a few millimetre to several centimetres in size, covered by intact mucosa and blanching on pressure. IHs were treated by DLP with 320 μm fibres at a wavelength of 800 ± 10 nm. The diode laser techniques applied were: Transmucosal DLP (DLTP), a no-contact technique in which laser energy is delivered by a flexible optic quartz fiber, which is kept 2–3 mm apart from the lesion, and Intralesional DLP (DLIP), in which the fibre is introduced into the lesion through a transmucosal access. DLTP was used for 20 flat, superficial IHs and, after a variable number of laser sessions (average = 3) depending on the size of the lesion, 65% completely regressed, while in the remaining 35% shrinkage of the lesion was achieved with minor and few complications.

The remaining 14 deep/multi-lobulated IHs were treated by DLIP, resulting in complete regression of 79% of them.

Conclusions

DLP techniques are an effective and minimally invasive procedure for IH in patients with PHACES, in consideration of the multiple lesions to treat, of the necessity of multiple interventions and the higher compliance of the patients.

Effectiveness of propranolol in the treatment of infantile hemangioma beyond the proliferation phase

During the last 5 years, many studies have shown the efficacy of propranolol as first-line treatment for infantile hemangiomas (IHs), but not much has been written about the role of propranolol beyond the proliferation phase of IH (>1 year). Our aim was to assess propranolol efficacy and safety in the treatment of patients older than 1 year. A retrospective study of patients older than 1 year diagnosed with IH and treated in our vascular anomalies clinic between 2009 and 2013 was performed. Eighteen patients older than 1 year with a diagnosis of IH (15 girls, 3 boys) were identified. The mean age at the time of initiation of treatment was 25.7 months (range 13-72 mos). Single lesions were observed in 13 patients and multiple lesions in 5. Fifteen patients had focal lesions and three had segmental. The median duration of treatment with oral propranolol was 11.8 months (range 2-33 mos). Complete response was observed in 72.2% of the patients and partial response in 27.8%. Recurrence was observed in three patients 4.7 months after completion of therapy (range 0.3-8 mos). These patients required further therapy with propranolol for 6 more months. Bradycardia was documented in two patients and night terrors in one patient, which led to discontinuation of treatment. In our experience, propranolol may be useful in the treatment of IHs beyond the proliferation phase (>1 year old), but more studies are needed to support this observation.

A randomized, controlled trial of oral propranolol in infantile hemangioma

BACKGROUND

Oral propranolol has been used to treat complicated infantile hemangiomas, although data from randomized, controlled trials to inform its use are limited.

METHODS

We performed a multicenter, randomized, double-blind, adaptive, phase 2-3 trial assessing the efficacy and safety of a pediatric-specific oral propranolol solution in infants 1 to 5 months of age with proliferating infantile hemangioma requiring systemic therapy. Infants were randomly assigned to receive placebo or one of four propranolol regimens (1 or 3 mg of propranolol base per kilogram of body weight per day for 3 or 6 months). A preplanned interim analysis was conducted to identify the regimen to study for the final efficacy analysis. The primary end point was success (complete or nearly complete resolution of the target hemangioma) or failure of trial treatment at week 24, as assessed by independent, centralized, blinded evaluations of standardized photographs.

RESULTS

Of 460 infants who underwent randomization, 456 received treatment. On the basis of an interim analysis of the first 188 patients who completed 24 weeks of trial treatment, the regimen of 3 mg of propranolol per kilogram per day for 6 months was selected for the final efficacy analysis. The frequency of successful treatment was higher with this regimen than with placebo (60% vs. 4%, P<0.001). A total of 88% of patients who received the selected propranolol regimen showed improvement by week 5, versus 5% of patients who received placebo. A total of 10% of patients in whom treatment with propranolol was successful required systemic retreatment during follow-up. Known adverse events associated with propranolol (hypoglycemia, hypotension, bradycardia, and bronchospasm) occurred infrequently, with no significant difference in frequency between the placebo group and the groups receiving propranolol.

CONCLUSIONS

This trial showed that propranolol was effective at a dose of 3 mg per kilogram per day for 6 months in the treatment of infantile hemangioma. (Funded by Pierre Fabre Dermatologie; ClinicalTrials.gov number, NCT01056341.).

The use of propranolol in the treatment of infantile haemangiomas: an update on potential mechanisms of action

Currently, propranolol is the preferred treatment for problematic proliferating infantile haemangiomas (IHs). The rapid action of propranolol has been shown to be especially dramatic in IHs involving dyspnoea, haemodynamic compromise, palpebral occlusion or ulceration. Another remarkable aspect of propranolol treatment revealed that the growth of the IHs was not only stabilized, but also that the improvement continued until complete involution was achieved, leading to a considerable shortening of the natural course of IH. However, the mechanisms underlying the effects of propranolol have not been fully elucidated. Recent studies have offered evidence of a variety of mechanisms. These include the promotion of pericyte-mediated vasoconstriction, the inhibition of vasculogenesis and catecholamine-induced angiogenesis, the disruption of haemodynamic force-induced cell survival, and the inactivation of the renin-angiotensin system. This review summarizes these mechanisms and the new concepts that are emerging in this area of research. Moreover, several molecular mechanisms by which propranolol may modify neovascularization in IH have also been proposed. The antihaemangioma effect of propranolol may not be attributable to a single mechanism, but rather to a combination of events that have not yet been elucidated or understood. Further studies are needed to evaluate and verify these mechanisms to gain a greater understanding of the effects of the intake of propranolol on haemangioma involution.

Incidence and treatment of infantile haemangioma in preterm infants

Infantile haemangioma (IH) are vascular tumours with a unique growth dynamic, mostly absent at birth, growth in the first months followed by involution over several years, often resulting in residual skin changes. Immune-histologically, IH cells are exclusively glucose transporter protein-1 positive.The incidence of IH is increasing with decreasing gestational age, from 1-4% in term infants to 23% in those of <1000 g birth weight, with a female and Caucasian predominance. Discovery of systemic and topical beta blockers as an effective treatment option resulted in a rapid shift away from systemic steroids towards these drugs. For preterm infants, however, data on efficacy, pharmacokinetics and long-term safety are sparse or absent. Topical treatment without systemic side effects like cryotherapy may thus be an attractive alternative at an early growth stage (<10 mm). Indications for treatment with beta blockers, mostly propranolol systemically and timolol maleat 0.5% topically, are currently extrapolated from studies in older infants. Both seem effective, but adverse effects on sleep, circulation and metabolism are well described for propranolol. Long-term outcome data for either drug are missing. In conclusion, evidence on optimal IH treatment in preterms is lacking despite their high incidence; pharmacokinetic and clinical studies are warranted.

A retrospective analysis of systemic propranolol for the treatment of complicated infantile haemangiomas

AIM

A small percentage of complicated infantile haemangiomas need early, safe and effective treatment, and the option of off-label systemic propranolol treatment has been in existence since 2008. The aim of this study was to provide greater insight into the drug's efficacy and side effects.

METHODS

We report our retrospective experiences of 207 paediatric patients treated with systemic propranolol for complicated infantile haemangiomas, which were photographed and analysed with a specific haemangioma score.

RESULTS

Systemic treatment was successful in 99.5% of the patients. The haemangioma score before treatment was 8.3 ± 3.3 and the score at the end of the treatment was 1.5 ± 1.4. The reduction in the haemangiomas was significant and did not show any differences when distributed according to different localisations or to the patients' ages. Relevant side effects that may have made it necessary to discontinue the treatment were not observed. However, there was a statistically significant reduction in heart rate during the first six in-hospital drug applications.

CONCLUSION

Our study demonstrates that systemic propranolol treatment is a highly effective treatment that is nearly always safe. These findings are a milestone for particularly complicated haemangiomas and provide highly valuable information on this drug treatment.

Infantile and congenital hemangiomas

Infantile hemangiomas (IHs) are the most common benign vascular tumors of infancy. Since they predominantly involute without significant residua, the majority do not require treatment. Indications for intervention include ulceration, prevention of disfigurement, and impairment of function or vital structures. Some IHs have associated structural anomalies. When and which IH to treat requires knowledge of the natural history and clinical findings of increased risk. Congenital hemangiomas (CHs) are fully formed at birth. They also differ from IHs in their histological and immunohistochemical findings and thus represent a distinct clinical entity. Their clinical characteristics and management are also discussed.

Vascular anomalies and airway concerns

Vascular anomalies, both tumors and malformations, can occur anywhere in the body, including the airway, often without any external manifestations. However, vascular anomalies involving the airway deserve special consideration as proper recognition and management can be lifesaving. In this article, the authors discuss vascular anomalies as they pertains to the airway, focusing on proper diagnosis, diagnostic modalities, and therapeutic options.

A further experience of propranolol for severe infantile hemangiomas of the face: an observational study

Infantile hemangiomas (IHs) are the most common proliferating embrional tumors of infancy, which are constituted by endothelial cell hyperproliferation. The authors want to report their observations of further 14 patients suffering from complicated IHs involving the facial district who were treated with propranolol. 14 patients, with ages between 3 and 12 months, completed a cycle of treatment with propanolol. The observational study aimed at focusing IHs involving the facial district. The treatment with propranolol showed good to very good results in the major part of the treated young patients. The authors want to report their experience and add more data in the confirmation of the use of β-blockers for IH (either in efficacy or in safety profile), focusing on the efficacy of propanolol when IHs involve the face.

Beta-blockers as therapy for infantile hemangiomas

Infantile hemangiomas (IH) are common benign vascular tumors seen in children. Although the majority will improve spontaneously without treatment, a small subset will require therapy due to a variety of complications. Less than a decade ago, propranolol replaced corticosteroids as first-line treatment for most IH and it has proven to be a relatively safe, effective therapy. After initiation of propranolol, most hemangiomas show evidence of significant improvement relatively rapidly, often within days. Although propranolol is generally felt to have a more limited side-effect profile than systemic corticosteroids, its use has been infrequently associated with adverse events, including sleep disturbances, acrocyanosis, hypotension, bradycardia, respiratory events, and hypoglycemia. Rarely, hypoglycemic seizures have been reported, usually occurring in the setting of prolonged fasting.

Treatment of periorbital infantile haemangiomas: a systematic literature review on propranolol or steroids

AIM

The aim of this study was to compare the efficacy and safety of propranolol versus corticosteroids for the treatment of periorbital infantile haemangiomas (IHs).

METHODS

A literature review using PubMed, Ovid Medline, EBSCO, Springer, Web of Knowledge, Cochrane Library, CNKI and associated references before 2 March 2013 was conducted. The main outcomes were distribution of locations, response rate, rebound growth rate, spherical and cylinder power before and after treatment, amblyopia rate and adverse events.

RESULTS

Thirty-one studies including 425 patients met the inclusion criteria. A total of 70.6% of patients were female, 89.6% of the periorbital IHs were located in the upper or lower eyelid area. The most common administration routes involved oral propranolol and intralesional injection of corticosteroids. The mean response rate was 94.0% for propranolol and 82.3% for corticosteroid (P = 0.001). The rebound growth rate was 13.9% for propranolol and 12.0% for steroids (P = 0.71). Astigmatism was reduced in both propranolol and steroid studies (P < 0.0001, P < 0.0001), but a significant reduction in spherical power was only demonstrated in propranolol studies (P = 0.005). A total of 31.1% of patients treated with corticosteroids developed post-operative amblyopia compared with 16.7% of patients treated with propranolol (P = 0.04). Oral propranolol seemed to induce more temporary adverse events than intralesional corticosteroids administration (24.0% vs. 9.6%, P = 0.006).

CONCLUSION

Propranolol may represent an effective therapy for periorbital IHs compared with the use of corticosteroids; however, further randomised control studies are needed to compare adverse events.

Haemangioma: clinical course, complications and management

Despite their high incidence, most infantile haemangiomas (IH) do not require treatment as they regress spontaneously and most do not leave significant sequelae. For the subset of haemangiomas that require treatment, indications for intervention can be divided into three main categories: ulceration, disfigurement and impairment of function or vital structures. In addition, certain IH have a risk of associated structural anomalies. Given the wide heterogeneity of haemangiomas, deciding which haemangiomas need intervention and when to intervene requires a detailed knowledge of natural history and clinical indicators of increased risk.

Induction of apoptosis in infantile hemangioma endothelial cells by propranolol

Propranolol, a non-selective β-blocker, is emerging as an effective treatment for complicated hemangiomas. The aim of this study was to investigate the molecular mechanism(s) underlying the therapeutic effects of propranolol against hemangiomas, using primary infantile hemangioma endothelial cells (IHECs). IHECs were treated with various concentrations of propranolol and morphological changes and apoptosis were assessed. Changes in the expression levels of apoptosis-related genes were examined. Annexin-V staining revealed that propranolol at 40, 50 and 60 μg/ml caused a concentration-dependent increase in the apoptosis of IHECs. Morphological analyses revealed that exposure to 50 μg/ml propranolol resulted in typical apoptotic changes, including shrinkage, the formation of apoptotic bodies and retention of plasma membrane integrity. Gene expression analyses revealed that propranolol treatment led to a marked increase in the expression of caspase-8, cytochrome c, apoptosis-inducing factor, caspase-3 and poly (ADP-ribose) polymerase 1, as well as a concomitant reduction in lamin B1 expression. Our data collectively demonstrate that propranolol induces apoptosis of IHECs through activation of the intrinsic and extrinsic apoptotic pathways, which represents an important mechanism for its therapeutic effects against infantile hemangiomas.