Successful treatment of oral itraconazole for infantile hemangiomas: a case series

Itraconazole Oral Solution for Infantile Complicated Hemangioma with Double Lesions on the Skin and One Inside the Liver

An infantile hemangioma is a congenital benign tumor formed by the proliferation of vascular cells during the embryonic stage. It is more common in the skin but can also occur in the mucous membranes, liver, brain and muscle. Hepatic hemangioma appears to be a benign tumor; however, it may lead to poor outcomes because of severe complications, such as high-output cardiac failure. The main treatment of hepatic hemangioma in infants is oral drugs, such as propranolol and glucocorticoids, but the clinical response is not always satisfactory. We describe a rare case of a 2-month-old boy who presented with infantile cutaneous and hepatic hemangiomas. By using dermoscopy and observations of the abdominal color Doppler ultrasound, after 9 months of oral treatment with itraconazole solution, the infantile cutaneous hemangioma complicated with hepatic hemangioma was eventually cured. There was no liver or kidney function damage during the whole treatment period. Itraconazole oral solution for the treatment of infantile cutaneous hemangioma complicated with hepatic hemangioma showed good efficacy, compliance, and safety in this case.

Repurposing of antiangiogenic agents for treatment of vascular anomalies

Vascular anomalies (VA) are developmental anomalies of veins, arteries, lymphatics or capillaries thought to be caused by mutations in genes that drive angiogenesis. Treatments targeting these genes are limited. We review the literature for conventional medications and products from traditional medicine cultures that have been found to have antiangiogenic activity. Fewer than 50 drugs with credible human activity in VA were identified and include β blockers, monoclonal antibodies, microtubule inhibitors, multi-kinase inhibitors, PIK3CA- and RAS-MAPK pathway inhibitors, and thalidomides. Other drug categories of potential interest are ACE-inhibitors, antifungals, antimalarials, MMP9-inhibitors, and over-the-counter compounds used in Eastern traditional medicine. Low toxicity for some offers the possibility of combined use with known effective agents. In addition to already familiar drugs, others with antiangiogenic capabilities already in use in children or adults may deserve further attention for repurposing for VA.

Itraconazole inhibits proliferation, induces apoptosis, and reduces angiogenesis of hemangioma endothelial cells by downregulating the hedgehog signaling pathway

Infantile hemangioma (IH) is among the most prevalent benign vascular tumours in infants. The pathogenesis of IH mainly involves abnormal proliferation of vascular endothelial cells and the formation of new vessels. Itraconazole was shown to be effective in treating IH; however, the mechanism underlying its action is still unclear. The purpose of this study was to examine the effects of itraconazole on the proliferation, apoptosis, and angiogenesis of hemangioma endothelial cells (HemECs); human umbilical vein endothelial cells served as the control group. The expression of genes involved in the hedgehog (HH) signaling pathway (SHH, PTCH1, SMO, and GLI1) was determined using real-time quantitative polymerase chain reaction. Western blotting was used to determine the expression of related proteins. In this study, itraconazole significantly dose- and time-dependently inhibited the viability of HemECs. Itraconazole suppressed the expression of PCNA, Ki67, and vascular endothelial growth factor (VEGF), demonstrating that this treatment inhibited cell proliferation and angiogenesis. Moreover, itraconazole induced apoptosis of HemECs by activating the expression of BAX and inhibiting the expression of BCL2. Itraconazole inhibited SHH, PTCH1, SMO, and GLI1 expression. Activation of the HH pathway by recombinant human sonic hedgehog (rhSHH) protein attenuated the effect of itraconazole on HemECs. In conclusion, itraconazole inhibits proliferation, induces apoptosis, and reduces angiogenesis of HemECs via the downregulation of the HH signaling pathway. Therefore, itraconazole may be an alternative choice for the treatment of IH.

Ranugha PS, Seetharam KA. IADVL SIG pediatric dermatology (academy) recommendations on Hemangioma of Infancy (HOI)

Hemangioma of infancy (HOI) is a benign vascular proliferation. Though resolution is the norm, potential complications make an accurate diagnosis and early management of importance. The Indian association of dermatologists, venereologists and leprologists (IADVL) special interest group (SIG) paediatric dermatology in association with IADVL academy did an extensive analysis of the literature on the clinical features, diagnosis, and management of HOI published between 2010 and 2021. Online meetings were conducted from February 2021 to March 2022 to reach a consensus on these recommendations which are made from an Indian perspective.

Auricular erythermalgia showing excellent response to itraconazole: a case report

Erythermalgia, a rare painful disorder, is characterized by recurrent pain attacking, warmth, and erythema that mainly involves the distal extremities. Red ear syndrome shares similar clinical features of erythermalgia afflicting the external ear with unilateral/bilateral distribution. The treatments of both diseases are still difficult without controlled therapeutics available up to date. A 12-year-old boy was referred because of 3 years of recurrent attacking of painful erythema and warmth that involved the ears alone, the episodes occurred several times daily with duration of dozens of minutes to hours for each flare. The symptoms could be relieved by cold water and triggered by heat stimuli as well as exciting and movement, and showed mild response to gabapentin, celecoxib, and topical lidocaine compounds in combination, but moderate to blocking injection of botulinum toxin to nervus auricularis magnus. However, systemic itraconazole 200 mg daily resulted in an excellent response after 5-week treatment, leading to milder erythema, warmth and burning sensation, shorter duration, and fewer relapses. The treatment continued for 6 months and then itraconazole was decreased to 100 mg daily for another 6 months until it was stopped, with maintenance of good conditions. In 3 months of follow-up after the treatment ceased, the patient had only 7 to 8 attacks over 10 days presenting as tolerable erythema that lasted for less than 10 min and relieved spontaneously, with absence of warmth and no need of treatment. We considered the patient to be a variant of erythermalgia rather than a red ear syndrome. The results showed that erythermalgia might involve the ears alone and itraconazole might be a potential agent for its treatment.

Itraconazole therapy for infant hemangioma: Two case reports

BACKGROUND

Infantile hemangiomas (IHs) are the most common childhood benign tumors, showing distinctive progression characteristics and outcomes. Due to the high demand for aesthetics among parents of IH babies, early intervention is critical in some cases. β-Adrenergic blockers and corticosteroids are first-line medications for IHs, while itraconazole, an antifungal medicine, has shown positive results in recent years.

CASE SUMMARY

In the present study, itraconazole was applied to treat two IH cases. The therapeutic course lasted 80-90 d, during which the visible lesion faded by more than 90%. Moreover, no obvious side effects were reported, and the compliance of the baby and parents was desirable.

CONCLUSION

Although these outcomes further support itraconazole as an effective therapeutic choice for IHs, large-scale clinical and basic studies are still warranted to improve further treatment.

Itraconazole Oral Solution for a Case of Infantile Hemangioma: Monitoring the Efficacy by Dermoscopy and MRI

Infantile hemangioma is a common and challenging benign vascular tumor. Although involution is spontaneous, approximately 10% of infantile hemangioma of large size or in specific locations may cause ulceration, severe cosmetic and functional problems that may require intervention. Treatment options include oral propranolol, topical timolol, and oral corticosteroids. However, the clinical response is not always satisfactory. We report the case of a 4-month-old boy who presented with an irregular erythematous plaque on his left shoulder 3 days after birth. Infantile hemangioma was diagnosed. Topical application of 0.5 ml of 0.5% timolol maleate eye drops for half an hour each time three times a day was initiated. After nearly 3 months of follow-up, the size of the lesion gradually increased. Finally, after 115 days of treatment with itraconazole oral solution (the total dose was about 4025 mg), the refractory infantile hemangioma was successfully treated. Hepatic and renal function remained normal with only mild diarrhea during the course of oral medication. Treatment compliance of oral itraconazole in infants has been reported to be good. Dermoscopy and magnetic resonance imaging (MRI) played a crucial role in in vivo observation of the hemangioma changes with vascular regression during the treatment process.

Paediatrics: how to manage infantile haemangioma

Infantile haemangiomas (IHs) are relatively common benign vascular tumours found in the paediatric population. They have varying sizes and involve different depths in the skin leading to various colours, shapes and textures. Although considered harmless in most cases, they may lead to life-threatening complications or cause permanent disfigurations and organ dysfunction. For problematic IHs, the treatment options include oral and topical beta-blockers, systemic corticosteroids, laser treatment, and surgery. In this narrative review, the treatment options for problematic IH are compared and delivered concisely to facilitate the clinical decisions from practitioners, including those in primary care settings. Oral propranolol is currently considered the first-line intervention for problematic IHs. For superficial lesions, there is robust evidence for the use of topical timolol maleate. Systemic corticosteroids are sometimes used in specific situations such as resistance or contraindications to beta-blockers. Surgical excision can be considered in cases requiring urgent intervention such as airway obstruction; this can be done alongside laser therapies for the removal of residual tissue or when reconstructing areas of deformity. The combination of multiple treatment modalities may lead to a more rapid clinical response.

Application of the adenosine triphosphate sensitivity assay in infantile vascular anomalies

Background

The term vascular anomalies include various vascular tumors and vascular malformations, among them infantile hemangiomas and capillary malformations are the most well-known associated diseases in early ages. Multiple drugs have been introduced for intervention, but susceptibility test in vitro were scarcely reported.

Objective

To evaluate the inhibition effect of different drugs by adenosine triphosphate sensitivity assay in vitro before the treatment of infantile hemangiomas and capillary malformations.

Methods

Specimens were selected from 5 cases of infantile hemangiomas and 11 cases of capillary malformations. Propranolol, rapamycin, sildenafil and itraconazole were tested for their growth inhibition effect by using the adenosine triphosphate sensitivity assay.

Results

Propranolol demonstrated inhibitory effects on infantile hemangiomas cells. Rapamycin and itraconazole both showed inhibitory effects on infantile hemangiomas cells and capillary malformations cells. Sildenafil has no growth inhibitory effect on infantile hemangiomas cells or capillary malformations cells.

Conclusion

Adenosine triphosphate sensitivity assay is a sensitive and useful testing method before the management of vascular anomalies, and individualized medication suggestions for the choice of therapeutic drugs were offered based on the testing result and together with a comprehensive evaluation of each infant.

Management of Head and Neck Hemangiomas in Adults: Oral Propranolol Versus Oral Itraconazole in Conjugation with Injection Sodium Tetra Decyl Sulphate

Management of head and neck hemangiomas with oral propranolol versus oral itraconazole in conjugation with injection sodium tetra decyl sulphate. This prospective parallel clinical trial was done to check for the effectiveness of oral propranolol and oral itraconazole when used in conjugation with inj. sodium tetra decyl sulphate in treatment of head and neck haemangiomas in adult patients visiting department of ENT and head and neck surgery, VIMSAR, Burla. All the patients visiting the department with hemangioma (diagnosed clinically and by FNAC) were considered and only those who gave written informed consent and were according to our inclusion and exclusion criteria were included into the study as subjects. Dimension (length, width and hemi-circumference) of the haemangiomas were measured using disposable paper taper measures. Depth of the hemangioma was calculated based on formula and using that volume was calculated both at baseline and after 8 weeks of drug administration. Data so collected was entered into Microsoft Office Excel 2013 and statistical analysis was performed using SPSS Version 20.0. Descriptive statistics was calculated and student's t test (paired and unpaired) was used to compare within the group (before and after) and between the groups respectively. Statistical significance was set at p ≤ 0.05. Both the groups showed statistically significant volume reduction in the lesions [p < 0.018 (propranolo + sodium tetra decyl sulphate), p < 0.025 (itraconazole + sodium tetra decyl sulphate)]. The mean decrease in volume in propranolol group was 91.92% and that in itraconazole group was 88.97%. There was no statistical difference between the final outcome of both the groups (p < 0.766) but 3 patients on propranolol had complete resolution while 1 patient on itraconazole had complete resolution of the lesion. Oral propranolol and itraconazole are both effective and safe in hemangioma in adults. The combination with inj. sodium tetra decyl sulphate has a (1) favorable impact on decreasing the overall duration of treatment. (2) Aiding in complete resolution of lesions (especially < 3 cm). Propranolol has an edge over itraconazole (more no of tumors had complete resolution).

Progress in the treatment of infantile hemangioma

Infantile hemangioma (IH) is a common benign tumor, which mostly resolves spontaneously; however, children with high-risk IH need treatment. Currently, the recognized first-line treatment regimen for IH is oral propranolol, but research on the pathogenesis of IH has led to the identification of new therapeutic targets, which have shown good curative effects, providing more options for disease treatment. This article summarizes the applications of different medications, dosages, and routes of administration for the treatment of IH. In addition to drug therapy, this article also reviews current therapeutic options for IH such as laser therapy, surgical treatment, and observation. To provide the best treatment, therapeutic regimens for IH should be selected based on the child's age, the size and location of the lesion, the presence of complications, the implementation conditions, and the potential outcomes of the treatment.

Itraconazole Versus Propranolol: Therapeutic and Pharmacologic Effect On Serum Angiopoietin-2 In Patients With Infantile Hemangioma

Background: The initial recommendation propranolol usage in managing infantile hemangioma was in 2008 followed by various researches assessing the dosage, efficacy and other parameters. Itraconazole is a world-wide tolerated antifungal but only a few studies have focused on its assessment in the treatment of IH.Objective: This study aim was to investigate the newly proposed antifungal drug ICZ and characterize different aspects of its usage as antiangiogenic drug.Methods: This is an interventional clinical trial to assess the efficacy of ICZ versus propranolol in the treatment of infantile hemangioma with studying the change in serum Ang2. A total of 36 pediatric patients were divided into two equal groups first treated with oral itraconazole, second treated by oral propranolol.Results: Response to treatment was observed using modified IH score. In itraconazole treated infants, good response was observed in 44.4% of the patients. This was slightly higher than the propranolol group which showed 22.2% with good response. We observed a decrease in serum ang2 level after usage of ICZ & propranolol and the change in serum angiopoietin2 level before and after treatment in each group was statistically significant (p < 0.001).Conclusion: Oral itraconazole can be an equivalent option for oral propranolol while safer and shorter treatment periods.

Itraconazole in the Treatment of Nonfungal Cutaneous Diseases: A Review

INTRODUCTION

The anti-inflammatory and pro-kinetic properties of antibiotics have been widely reported. However, the non-antifungal properties of antifungal agents are less well known and less explored in clinical practice. The purpose of this review was to survey the literature on the non-antifungal use of itraconazole in dermatological practice and the possible modes of action of this agent.

METHODS

The PubMed database was searched for relevant articles published up to January 2017. The references in the articles identified by the search were then hand-searched for additional relevant publications.

RESULTS

Itraconazole displays a great diversity of non-antifungal activity and has been used to treat a broad spectrum of diseases. The results of our survey reveal that itraconazole has the potential to be an alternative agent for treating patients with advanced cancer (either alone or in combination with other cytotoxic chemotherapeutic drugs), especially those refractory to traditional treatments. Moreover, itraconazole acts as an anti-angiogenesis agent, induces nail growth, and modulates inflammatory or immune diseases.

CONCLUSION

Oral antifungal agents have many non-antifungal properties. However, the body of evidence on individual agents often remains limited due to the lack of large-scale randomized controlled studies. Although some of the findings published to date seem promising, pharmacological vigilance should be taken for off-label use in real-world practice.

Itraconazole Induces Regression of Infantile Hemangioma via Downregulation of the Platelet-Derived Growth Factor-D/PI3K/Akt/mTOR Pathway

Infantile hemangioma is the most common benign vascular tumor of infancy. We have previously reported that itraconazole, a common antifungal agent, can clinically improve or cure infantile hemangioma; however, the underlying molecular mechanisms are still unclear. Here, we show that itraconazole treatment significantly inhibits proliferation and promotes apoptosis of the endothelial cells of mouse hemangioma cell line and infantile primary hemangioma endothelial cell. Itraconazole also remarkably reduced angiogenesis of hemangioma endothelial cell in vitro. We further performed transcriptome profiling via mRNA microarrays in hemangioma endothelial cell upon itraconazole treatment, and identified cytokine-cytokine receptor interaction as the top significantly enriched pathway. Importantly, itraconazole significantly reduced platelet-derived growth factor-D level, resulting in suppression of platelet-derived growth factor-β activation and inhibition of its downstream effectors, such as PI3K, Akt, 4E-BP1, and p70S6K, which are important for cellular growth and survival of infantile hemangioma. In conclusion, our results suggest that platelet-derived growth factor-D is a target of itraconazole in infantile hemangioma.

Intolerable side effects during propranolol therapy for infantile hemangioma: frequency, risk factors and management

Currently, propranolol is the most preferred systemic therapy for problematic infantile hemangiomas (IHs). However, the side effects such as bronchial hyperreactivity may be intolerable. The aim of this study was to evaluate the frequency, risk factors and management of intolerable side effects (ISEs) during propranolol therapy. In total, 1260 children were studied. The incidence of ISEs was 2.1% (26 patients). Severe sleep disturbance was the most common reason for propranolol cessation, accounting for 65.4% of cases. In total, 23 and 3 patients received atenolol and prednisolone as second-line therapy, respectively. Treatment response was observed in 92.3% (24/26) of cases (showing excellent or good response to therapy). No toxicity-related permanent treatment discontinuation occurred during atenolol or prednisolone therapy. In the univariate analysis, younger age, premature birth, and lower body weight were associated with ISEs (P < 0.05). In the multivariate analysis, only age (95% confidence interval [CI]: 1.201-2.793, P = 0.009) and body weight (95% CI: 1.036-1.972, P = 0.014) were associated with ISEs. Our study suggests that ISEs are rare in patients with IHs who are treated with propranolol. Predictive factors for ISEs include younger age and lower body weight. Atenolol and prednisolone are effective and safe alternatives to propranolol in the treatment of refractory IHs.

Current trends in medical management of infantile hemangioma

PURPOSE OF REVIEW

Infantile hemangiomas are the most common benign, soft-tissue tumors of infancy, affecting between 5 and 10% of newborns, and up to 30% of premature infants. Morbidity may include disfigurement and scarring, difficulty in feeding, ulceration, vision loss, airway compromise, congestive heart failure, and death. Advances in understanding the pathogenesis of infantile hemangiomas have given rise to a number of promising treatments. This article reviews the current options for medical management of infantile hemangiomas.

RECENT FINDINGS

In the proliferative phase of infantile hemangiomas, vascular endothelial growth factor and basic fibroblast growth factor have shown increased expression, and vascular endothelial growth factor expression has been up-regulated by adrenergic stimulation. Moreover, the role of the renin-angiotensin system in the pathogenesis of infantile hemangiomas has been demonstrated. Numerous medical options have been under investigation. Since 2008, propanolol has become the first-line therapy, whereas other medical treatments are used less frequently or when propanolol is unsuccessful.

SUMMARY

Propranolol has been recently adopted as the first-line medical treatment for complicated infantile hemangiomas. Although emerging treatment options and modalities have shown promising results, there need to be high-quality multicenter randomized trials to support these preliminary data.

Propranolol for infantile hemangioma: Current state of affairs

Infantile hemangioma (IH) is the most common benign tumor seen in infancy. This review provides up-to-date information on the pathophysiology, variations in clinical presentation, and natural history of IH, elaborating on associated anomalies, such as PHACE(S) syndrome and LUMBAR syndrome. Because of the benign and self-limiting characteristics seen in more than 90% of cases of IH, a conservative approach is usually chosen. However, some circumstances, such as ulceration, vision loss, breathing difficulties, or potential disfigurement, will require treatment during the proliferative phase. For decades, treatment of IH has primarily consisted of corticosteroids or surgery. Since 2008, propranolol has become the treatment of first choice. In this article, we bring to light the crucial changes in the treatment of IH over the past years. To date, there is still a lack of data on the possible long-term effects of propranolol treatment in young infants. A theoretical probability of the central nervous system being affected (that is, impairment of short- and long-term memory, psychomotor function, sleep quality, and mood) has recently been suggested. This review highlights research topics concerning these long-term adverse effects. Finally, information is provided on the potential instruments to measure IH severity and activity in clinical trials and/or in clinical practice and the recently developed and first-validated IH-specific quality-of-life questionnaire.

Repurposing Drugs in Oncology (ReDO)-itraconazole as an anti-cancer agent

Itraconazole, a common triazole anti-fungal drug in widespread clinical use, has evidence of clinical activity that is of interest in oncology. There is evidence that at the clinically relevant doses, itraconazole has potent anti-angiogenic activity, and that it can inhibit the Hedgehog signalling pathway and may also induce autophagic growth arrest. The evidence for these anticancer effects, in vitro, in vivo, and clinical are summarised, and the putative mechanisms of their action outlined. Clinical trials have shown that patients with prostate, lung, and basal cell carcinoma have benefited from treatment with itraconazole, and there are additional reports of activity in leukaemia, ovarian, breast, and pancreatic cancers. Given the evidence presented, a case is made that itraconazole warrants further clinical investigation as an anti- cancer agent. Additionally, based on the properties summarised previously, it is proposed that itraconazole may synergise with a range of other drugs to enhance the anti-cancer effect, and some of these possible combinations are presented in the supplementary materials accompanying this paper.