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Propranolol for Infantile Hemangioma: Safety Issues and Proposed Protocol

Case reports describe adverse events associated with this agent.

Infantile hemangiomas (IHs) are common, self-limited vascular tumors that usually require no intervention. However, some hemangiomas require treatment to preserve function (visual, airway) or treat ulceration. The usual treatment is systemic glucocorticoids (typically prednisolone at 2 mg–5 mg/kg/day). Interferon alfa, vincristine, and cyclosporine are other therapeutic options, but these agents have increased risks compared to steroids. In 2008, a series of 11 IHs were successfully treated with oral propranolol, with responses that appeared to be faster and better than with corticosteroids (JW Dermatol Jun 20 2008). Although issues of administration and safety were not discussed, propranolol use by pediatric dermatologists has increased. Now, these authors discuss the cases of two infants who developed complications during propranolol treatment for IH.

An 8-week-old girl received systemic corticosteroids for an eyelid hemangioma. After 2 weeks without response, propranolol was started (2 mg/kg/day divided every 12 hours). After two doses, she became lethargic. Emergency department evaluation revealed bradycardia and hypotension, but the infant stabilized spontaneously without further complication. A 36-day-old girl with diffuse neonatal hemangiomatosis (>100 cutaneous and hepatic hemangiomas) was treated with propranolol (2 mg/kg/day divided every 8 hours). After 10 days, a critically low but asymptomatic blood-sugar level was noted. The patient presumably recovered and was able to continue propranolol. The case of an additional infant with an eyelid hemangioma who developed bradycardia and hypoglycemia while receiving propranolol is also mentioned in an accompanying editorial.

Comment: Adverse effects of propranolol are bradycardia, hypotension, hypoglycemia, and bronchospasm. High-output cardiac failure can occur in infants with very large IH, PHACES syndrome, PELVIS syndrome, and, especially, diffuse neonatal hemangiomatosis (miliary type). Until safety and efficacy data are available (a double-blind placebo-controlled trial is underway), a treatment protocol that the study authors describe is very useful. Appropriate evaluation (e.g., PHACES work-up and cardiology consultation) should be considered prior to initiation. Propranolol's mechanism of action against IH is unknown. The editorialists note that in African Americans, who have the lowest incidence of IH, genetic polymorphisms in the G protein–coupled receptor kinases are common, and these may provide an endogenous form of beta blockade.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology November 6, 2009

Citation(s):

Lawley LP et al. Propranolol Treatment for Hemangioma of Infancy: Risks and Recommendations. Pediatr Dermatol 2009 Sep/Oct; 26:610.

• Medline abstract (Free)

Frieden IJ and Drolet BA. Propranolol for Infantile Hemangiomas: Promise, Peril, Pathogenesis. Pediatr Dermatol 2009 Sep/Oct; 26:642.

• Medline abstract (Free)

Reader Remarks:

Review and add to remarks on this article

• Infantile Hemangioma Treatment
  Andy J Dino, 5 May 2010 2:10 PM EST
  My specialty is adult Transfusion Medicine and Hematology. My interest stems from a 19 month old grandchild with IH of... [more]
• infantile haemangioma
  mohamed shawky, boulak el dakrour hospital, 29 Nov 2011 12:15 PM EST
  Specialty: General Surgery
  what is the pharmacological form of proppranolol given to infants ? can it be used locally ?

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