Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

BACKGROUND

Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment.

OBJECTIVES

To provide unified guidelines for the treatment of IH with propranolol.

METHODS

This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS

The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.

CONCLUSIONS

These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making.

Laser for vascular anomalies: successful outcomes in children

Vascular anomalies can cause both emotional and physical distress to patients, particularly children. The paediatric laser service at Great Ormond Street Hospital (GOSH) treats a range of dermatological conditions including a variety of vascular anomalies, excess hair growth and disfiguring scars. The laser team at GOSH has 25 years of experience in treating a wide variety of paediatric dermatological conditions using various laser therapies. With over 600 new referrals for laser therapy and over 1000 laser procedures each year the GOSH laser team has vast amounts of experience with both common and rare conditions. Excellent clinical outcomes continue to be delivered, and new treatment therapies are constantly being developed to treat more recalcitrant lesions. The adverse effect rates experienced by the GOSH laser patients have been decreasing over the past two decades, reaching the low rate of 0.8% per treated patients per year. This remarkable achievement has been continuously improved by integrating specific and standardized laser protocols for each patient treated, to ensure efficacious and safe laser treatment delivery. Treating vascular anomalies with laser therapy creates significant positive results among the paediatric population, thus laser therapy at GOSH makes a significant impact upon children's lives with both rare and common vascular anomalies.

Propranolol and prednisolone combination for the treatment of segmental haemangioma in PHACES syndrome

Posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe syndrome (also known as PHACES syndrome) is a rare neurocutaneous disorder. Children presenting with these manifestations need careful ophthalmological, cardiac and neurological assessment. They may have one or more of these extracutaneous manifestations, the most common being cerebral and cardiovascular anomalies. There is controversy about treating these children with propranolol especially if they have cerebrovascular involvement with narrow, dysplastic or absent blood vessels. The concern with propranolol is that hypotension may lead to reduced cerebral blood flow and neurological consequences. Prior to propranolol the systemic treatment for haemangiomas was prednisolone and then the concern was the opposite, namely hypertension. Our proposal was whether a combination of these two drugs would provide a safer and faster recovery. We report three retrospective cases of PHACES syndrome, each of whom received treatment with a combination of propranolol and prednisolone: two children were started on prednisolone and propranolol was added because the haemangiomas failed to respond adequately; the third child was started on propranolol and developed peripheral ischaemia and ulceration necessitating a reduction in dose addition of a low dose of prednisolone. All three patients, who failed on the one treatment, responded well to combination therapy without any significant complications. These outcomes suggest that for some patients with PHACES syndrome the use of combination treatment with propranolol and prednisolone could be advantageous, potentially allowing for the introduction of low doses of each with an enhanced combined effect. The doses can be increased gradually depending on the magnetic resonance imaging findings.

African partnerships for patient safety: a vehicle for enhancing patient safety across two continents. [corrected]

African Partnerships for Patient Safety (APPS) aims to develop sustainable partnerships between hospitals in Africa and Europe to create a network of beacon hospitals for patient safety. The three core APPS objectives are focused on building strong patient safety partnerships between hospitals in Africa and Europe, implementing patient safety improvements in each partnership hospital on 12 patient safety action areas, and facilitating spread of patient safety improvements. APPS is working with six first wave hospital partnerships and will capture and report learning from implementation. A range of APPS resources will shortly be available to hospitals working on patient safety systems.