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Roupakias S, Kostopoulou E, Gkentzi D, Fouzas S, Sinopidis X. Infantile hemangiomas screening modalities for primary care physicians. Pediatr Investig 2023; 7:199-205. [PMID: 37736361 PMCID: PMC10509409 DOI: 10.1002/ped4.12383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/23/2023] [Indexed: 09/23/2023] Open
Abstract
Infantile hemangiomas are the most common benign vascular tumors in children. They present a characteristic natural history of spontaneous involution after a phase of initial proliferation. A small but significant minority demonstrates incomplete regression or complications and requires prompt intervention. Prediction of the evolution of infantile hemangiomas is challenging because of their morphological and behavioral heterogeneity. The decision between referral for treatment and observation is sometimes difficult, especially among non-expert physicians, with the risk of missing the period for optimizing outcomes in case of delayed intervention. The aim of this review is to update our knowledge, especially of the primary care providers, regarding the ongoing difficulties of the early clinical evaluation of infantile hemangiomas, and to outline the importance of current practical scoring tools for the identification of the lesions which require expert consultation and referral.
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Affiliation(s)
- Stylianos Roupakias
- Department of Pediatric SurgeryUniversity of Patras School of MedicinePatrasGreece
| | - Eirini Kostopoulou
- Department of PediatricsUniversity of Patras School of MedicinePatrasGreece
| | - Despoina Gkentzi
- Department of PediatricsUniversity of Patras School of MedicinePatrasGreece
| | - Sotirios Fouzas
- Department of PediatricsUniversity of Patras School of MedicinePatrasGreece
| | - Xenophon Sinopidis
- Department of Pediatric SurgeryUniversity of Patras School of MedicinePatrasGreece
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Bar J, Bar‐Ilan E, Cleper R, Sprecher E, Samuelov L, Mashiah J. Monitoring oral propranolol for infantile hemangiomata. Dermatol Ther 2022; 35:e15870. [PMID: 36177767 PMCID: PMC9788279 DOI: 10.1111/dth.15870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/15/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
Abstract
Treating infantile hemangiomas with oral propranolol may be initiated in accordance with various protocols some require hospitalization. However, different adverse events have been reported during treatment, thus it is of special importance to find a protocol which is both safe and feasible. We performed a retrospective cohort study of all cases of infantile hemangiomas treated with oral propranolol at our institute between January 2010 and February 2020. Pretreatment evaluation consisted of pediatric cardiologist evaluation including electrocardiography and echocardiography. The propranolol starting dosage was 0.5 mg/kg bid; 2 weeks later the dosage was escalated to 1 mg/kg bid. During the initiation and escalation visits, heart rate and blood pressure were measured before and every hour for a total of 3 h, and blood glucose level was measured within the first hour of treatment. A total of 131 children were treated during the study period. Scalp, facial and genital region infantile hemangiomas were more prevalent in regard to their relative body surface area. No symptomatic bradycardia, hypotension, hypoglycemia, or any other adverse events were documented; few patients had asymptomatic bradycardia and hypotension, which were more common in infants below 6-months of age. Only one patient had asymptomatic hypoglycemia, not requiring any intervention. Initiation and escalation of propranolol treatment for infantile hemangiomas proved to be safe, and without symptomatic adverse effects. However, considering the young age of the patients and the possible asymptomatic adverse reactions, we recommend the following simple protocol as presented, for pretreatment evaluation and short monitoring during treatment initiation and dose escalation.
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Affiliation(s)
- Jonathan Bar
- Division of DermatologyTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Efrat Bar‐Ilan
- Division of DermatologyTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Roxana Cleper
- Pediatric Nephrology UnitDana‐Dwek Children's Hospital, Tel Aviv Sourasky Medical CenterTel AvivIsrael,Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Eli Sprecher
- Division of DermatologyTel Aviv Sourasky Medical CenterTel AvivIsrael,Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael,Pediatric Dermatology ClinicDana‐Dwek Children's Hospital, Tel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Liat Samuelov
- Division of DermatologyTel Aviv Sourasky Medical CenterTel AvivIsrael,Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael,Pediatric Dermatology ClinicDana‐Dwek Children's Hospital, Tel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Jacob Mashiah
- Division of DermatologyTel Aviv Sourasky Medical CenterTel AvivIsrael,Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael,Pediatric Dermatology ClinicDana‐Dwek Children's Hospital, Tel Aviv Sourasky Medical CenterTel AvivIsrael
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Püttgen KB, Hansen LM, Lauren C, Stefanko N, Mathes E, Olsen GM, Tollefson MM, Adams D, Baselga E, Chamlin S, Corey K, Frascari FF, Frieden IJ, Galligan ER, Gupta D, Haggstrom A, Horii K, Hornik CP, Klajn J, Liberman L, Mancini A, Mannschreck D, McGinness A, McCuaig C, Newell B, Nguyen H, Nopper A, Oyesanya T, Powell J, Reynolds M, Rios M, Siegel DH, Ward K, Garzon MC, Frommelt P, Drolet BA. Limited utility of repeated vital sign monitoring during initiation of oral propranolol for complicated infantile hemangioma. J Am Acad Dermatol 2021; 85:345-352. [PMID: 32289387 DOI: 10.1016/j.jaad.2020.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Initial propranolol recommendations for infantile hemangioma published in 2013 were intended as provisional best practices to be updated as evidence-based data emerged. METHODS A retrospective multicenter study was performed to evaluate utility of prolonged monitoring after first propranolol dose and escalation(s). Inclusion criteria included diagnosis of hemangioma requiring propranolol of greater than or equal to 0.3 mg/kg per dose, younger than 2 years, and heart rate monitoring for greater than or equal to 1 hour. Data collected included demographics, dose, vital signs, and adverse events. RESULTS A total of 783 subjects met inclusion criteria; median age at initiation was 112 days. None of the 1148 episodes of prolonged monitoring warranted immediate intervention or drug discontinuation. No symptomatic bradycardia or hypotension occurred during monitoring. Mean heart rate change from baseline to 1 hour was -8.19/min (±15.54/min) and baseline to 2 hours was -9.24/min (±15.84/min). Three preterm subjects had dose adjustments because of prescriber concerns about asymptomatic vital sign changes. No significant difference existed in pretreatment heart rate or in heart rate change between individuals with later adverse events during treatment and those without. CONCLUSION Prolonged monitoring for initiation and escalation of oral propranolol rarely changed management and did not predict future adverse events. Few serious adverse events occurred during therapy; none were cardiovascular.
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Affiliation(s)
| | | | | | | | - Erin Mathes
- University of California-San Francisco, San Francisco, California
| | | | | | | | | | - Sarah Chamlin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Flora F Frascari
- University of California-San Francisco, San Francisco, California
| | - Ilona J Frieden
- University of California-San Francisco, San Francisco, California
| | | | - Deepti Gupta
- Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington
| | | | | | | | - Justyna Klajn
- University of California-San Francisco, San Francisco, California
| | | | - Anthony Mancini
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Anelah McGinness
- University of California-San Francisco, San Francisco, California
| | | | | | | | - Amy Nopper
- University of Missouri, Kansas City, Missouri
| | - Tola Oyesanya
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julie Powell
- Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
| | - Megan Reynolds
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Monica Rios
- Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Kendra Ward
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Beth A Drolet
- School of Medicine and Public Health, University of Wisconsin, Milwaukee, Wisconsin.
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Pam N, Kridin K, Khamaysi Z. Propranolol for infantile hemangioma: Evaluating efficacy and predictors of response and rebound growth. Dermatol Ther 2021; 34:e14936. [PMID: 33704861 DOI: 10.1111/dth.14936] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/13/2021] [Indexed: 12/26/2022]
Abstract
Propranolol emerged as the first-line therapy for infantile hemangioma (IH). Determinants of interindividual variation in drug response and predictors of rebound growth after drug discontinuation are yet to be firmly established. We aimed to evaluate the outcomes of a relatively large cohort of patients with IH treated by propranolol and to determine predictors of (a) an excellent response to treatment (≥90 improvement) and (b) of rebound growth after drug cessation. A retrospective cohort study was conducted to follow all patients with IH receiving systemic propranolol in a referral center-based specialized clinic. Multivariate logistic regression analysis was performed to identify predictors of excellent response and rebound growth. The study included 206 patients who completed oral propranolol treatment. The mean (SD) age in which the drug was initiated was 4.8 (3.1) months. The average improvement rate was estimated at 85.5 (13.8)%. Initiation of propranolol at the age of 0 to 3 (adjusted odds ratio [OR], 3.43; 95% confidence interval [CI], 1.25-9.40; P = .016) and 3 to 6 (adjusted OR, 3.71; 95% CI, 1.50-9.19; P = .005) months was associated with an increased likelihood of excellent response. Twenty-four (11.7%) patients developed rebound growth following cessation of propranolol. No significant predictors of rebound were identified in the multivariate analysis. Eleven (5.3%) patients experienced mild adverse events, which necessitated drug discontinuation in only two (1.0%) patients. Propranolol is highly effective and safe based on the real-life experience of a referral center for IH. The current study supports early initiation of propranolol.
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Affiliation(s)
- Nadav Pam
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Ziad Khamaysi
- Department of Dermatology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Olsen GM, Hansen LM, Stefanko NS, Mathes E, Puttgen KB, Tollefson MM, Lauren C, Mancini AJ, McCuaig CC, Frieden IJ, Adams D, Baselga E, Chamlin S, Gupta D, Frommelt P, Garzon MC, Horii K, Klajn J, Maheshwari M, Newell B, Nguyen HL, Nopper A, Powell J, Siegel DH, Drolet BA. Evaluating the Safety of Oral Propranolol Therapy in Patients With PHACE Syndrome. JAMA Dermatol 2020; 156:186-190. [PMID: 31825455 DOI: 10.1001/jamadermatol.2019.3839] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Oral propranolol is widely considered to be first-line therapy for complicated infantile hemangioma, but its use in patients with PHACE (posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects, eye anomalies) syndrome has been debated owing to concerns that the cardiovascular effects of the drug may increase the risk for arterial ischemic stroke. Objective To assess the incidence of adverse events among patients with PHACE syndrome receiving oral propranolol for infantile hemangioma. Design, Setting, and Participants This multicenter retrospective cohort study assessed the incidence of adverse events among 76 patients with PHACE syndrome receiving oral propranolol for infantile hemangioma at 11 tertiary care, academic pediatric dermatology practices. Medical records from January 1, 2010, through April 25, 2017, were reviewed. Exposures Patients received oral propranolol, 0.3 mg/kg/dose or more. Main Outcomes and Measures The main outcome was the rate and severity of adverse events occurring throughout the course of treatment with oral propranolol, as documented in the medical records. Adverse events were graded from 1 to 5 using a scale derived from the Common Terminology Criteria for Adverse Events and were considered to be serious if they were grade 3 or higher. Results A total of 76 patients (59 girls and 17 boys; median age at propranolol initiation, 56 days [range, 0-396 days]) met the inclusion criteria. There were no reports of serious adverse events (ie, stroke, transient ischemic attack, or cardiovascular events) during treatment with oral propranolol. A total of 46 nonserious adverse events were reported among 29 patients (38.2%); the most commonly reported nonserious adverse events were sleep disturbances and minor gastrointestinal tract and respiratory tract symptoms. In a comparison with 726 infants who received oral propranolol for hemangioma but did not meet criteria for PHACE syndrome, there was no significant difference in the rate of serious adverse events experienced during treatment (0 of 76 patients with PHACE syndrome and 3 of 726 patients without PHACE syndrome [0.4%]). Conclusions and Relevance This study found that oral propranolol was used to treat infantile hemangioma in 76 patients with PHACE syndrome and that no serious adverse events were experienced. These data provide support for the safety of oral propranolol in this patient population.
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Affiliation(s)
- Gerilyn M Olsen
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Leanna M Hansen
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | | | - Erin Mathes
- Department of Dermatology, University of California, San Francisco
| | - Katherine B Puttgen
- Department of Dermatology, John Hopkins University School of Medicine, Baltimore, Maryland.,Department of Dermatology, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Christine Lauren
- Department of Dermatology, Columbia University, New York, New York
| | - Anthony J Mancini
- Department of Pediatrics, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Dermatology, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Catherine C McCuaig
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
| | - Ilona J Frieden
- Department of Dermatology, University of California, San Francisco
| | - Denise Adams
- Department of Hematology, Boston Children's Hospital, Boston, Massachusetts
| | - Eulalia Baselga
- Pediatric Dermatology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sarah Chamlin
- Department of Pediatrics, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Dermatology, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Deepti Gupta
- Division of Dermatology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Peter Frommelt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Maria C Garzon
- Department of Dermatology, Columbia University, New York, New York
| | - Kimberly Horii
- Division of Dermatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Justyna Klajn
- Department of Hematology, Boston Children's Hospital, Boston, Massachusetts
| | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, Milwaukee
| | - Brandon Newell
- Division of Dermatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Henry L Nguyen
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
| | - Amy Nopper
- Division of Dermatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Julie Powell
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
| | - Dawn H Siegel
- Department of Dermatology, Medical College of Wisconsin, Milwaukee
| | - Beth A Drolet
- Department of Dermatology, Medical College of Wisconsin, Milwaukee.,Department of Dermatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison
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Zeng L, Tao C, Liu Z, Zhang J, Zhang M, Zhang J, Fang S, Ma X, Song H, Zhou X. Preparation and Evaluation of Cubic Nanoparticles for Improved Transdermal Delivery of Propranolol Hydrochloride. AAPS PharmSciTech 2020; 21:266. [PMID: 33006694 DOI: 10.1208/s12249-020-01809-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022] Open
Abstract
Transdermal drug delivery of propranolol hydrochloride (PRH) is promising for the treatment of infantile hemangioma (IH). Clinically used PRH hydrogel fails to reach the deep IH for complete recovery. In this study, the PRH-loaded cubic nanoparticles (CNPs) were prepared to promote the transdermal effect of PRH. A remote drug loading method was developed to prepare the PRH-CNPs. For the traditional passive drug loading method, the largest encapsulation efficiency (EE%) was around 50%. The remote drug loading was performed by increasing the pH of the mixture of blank CNPs and PRH solution. The optimal PRH-CNPs showed an EE% of 90.15 ± 2.44% at pH 8.5. The permeation of the PRH solution was poor while the PRH-CNPs showed greatly enhanced skin permeation. It was found that smaller-sized PRH-CNPs contributed to increased skin permeation and retention. In addition, the PRH-CNPs had higher cytotoxicity towards the EOMA cells when compared with the PRH solution. During storage for 1 month, the PRH-CNPs kept stable size distribution, pH, and EE%. In conclusion, results of this study suggested that the PRH-CNPs could be a potential candidate for the treatment of the IH by transdermal delivery.
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Zhang JW, Yin SY, Zhou DK, Wen JX, Gao H, Chen L, Wang ZX. Quantitative Evaluation of Percutaneous Local Drug Perfusion Against Refractory Infantile Hemangioma via 3-D Power Doppler Angiography. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:610-619. [PMID: 31810804 DOI: 10.1016/j.ultrasmedbio.2019.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 10/26/2019] [Accepted: 11/04/2019] [Indexed: 06/10/2023]
Abstract
To assess the practicality of 3-D power Doppler angiography (3-D-CPA) for local drug perfusion dosage guidance of refractory infantile hemangioma (IH) treatment, 47 cases (48 lesions) of refractory IH were selected for local bleomycin infusion (once a month). Ultrasound was performed before treatment and 1 and 2 months after the first treatment. The 3-D volume (V) change of infantile hemangiomas and the ratio of bleomycin injection to 3-D V before treatment were calculated, and statistical analysis was performed. One month after percutaneous local drug perfusion, 37 participants (77.08%) exhibited significant improvement; controlled growth was observed on six lesions (12.5%); and treatment of the remaining 5 lesions (10.42%) failed to suppress growth. The calculated tolerable and effective dose of bleomycin for refractory IH was 0.34 ± 0.03 mL/cm3; the corresponding 3-D V decreased approximately 70.27 ± 6.27%. Three-dimensional CPA can provide abundant information on internal lesions. In particular, 3-D-CPA can quantitatively assess changes in lesion volume and guide the effective and rational use of interventional drugs.
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Affiliation(s)
- Jin-Wei Zhang
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Shu-Yue Yin
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - De-Kai Zhou
- Department of Hemangioma, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jie-Xin Wen
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hui Gao
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Lu Chen
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhao-Xia Wang
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China.
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Effects of propranolol therapy in Moroccan children with infantile hemangioma. Arch Pediatr 2018; 25:449-451. [PMID: 30361087 DOI: 10.1016/j.arcped.2018.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 08/26/2018] [Accepted: 09/23/2018] [Indexed: 11/22/2022]
Abstract
Infantile hemangiomas are the most common childhood vascular tumors. Propranolol is a β-adrenergic blocker that has proven effective in the treatment of this tumor. Numerous studies around the world have been published, describing satisfactory responses in pediatric populations with a higher cure rate and fewer adverse effects than when using corticosteroids. The aim of this study was to evaluate the efficacy and adverse effects of propranolol in Moroccan pediatric patients diagnosed with infantile hemangioma who were treated with oral propranolol. A prospective study was conducted from May 2009 to May 2017 in the department of dermatology of a hospital in Casablanca. All the patients who had infantile hemangioma were included. The study comprised 121 patients with infantile hemangioma: 90 girls and 31 boys. The mean age was 6 months. The majority of hemangiomas were mixed (63%) and located on the face and neck. The treatment was well tolerated by all the patients. The dosage of propranolol was gradually increased from 1mg to 2mg/kg/day. We noted a decrease in coloration after 48hours. The healing period for ulcerated hemangiomas was 20 days. A decrease in size was noted after 1 month, while a decrease in palpebral obstruction occurred after 3 days. Treatment with propranolol in this group of Moroccan pediatric patients proved to be safe and effective at a dose of 2 mg/kg/day, reducing the size and coloration of the hemangioma. Treatment should be stopped at an appropriate time, which is determined primarily by the lesion regression rate after propranolol treatment.
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