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Topical Timolol Solution for Infantile Hemangioma of the Eyelid

For thin hemangiomas, at least, this topical beta-blocker may be safe and effective.

Infantile hemangiomas located near the eye may cause amblyopia, astigmatism, proptosis, ptosis, permanent visual impairment, and even blindness. Until recently, oral corticosteroids have been the standard treatment. Less commonly used options include intralesional corticosteroids, interferon alpha 2a, laser, embolization, immunomodulators, and surgery. Since the off-label use of systemic propranolol for infantile hemangiomas was first reported (JW Dermatol Jun 20 2008), its use in hemangioma treatment has grown. However, all systemic therapies for hemangiomas carry risks for adverse effects (JW Dermatol Nov 6 2009). Some investigators have focused on the use of another beta-blocker, timolol. Timolol solution is the most commonly prescribed therapy for childhood glaucoma; this is the first report of timolol used for periocular hemangioma.

The authors describe a 4-month-old girl with a thin-plaque hemangioma on the upper eyelid that caused blepharoptosis, occlusion of the pupil, and decreased visual function. The ophthalmologist prescribed timolol solution, applied topically by the mother's fingertip twice daily to the surface of the hemangioma. No systemic medication was given. After 5 weeks, the hemangioma was significantly reduced in size, thickness, and color, and the visual axis was unobstructed. Topical timolol was discontinued at 7 weeks. At 11 weeks, improved visual function was documented. There were no adverse effects.

Comment: The prospect of a safe and effective topical medication for superficial hemangiomas has long been enticing. High-potency topical steroids and topical imiquimod have been tried, with mixed results; these agents are not recommended if vision is compromised and rapid therapeutic response is needed. A dermatologic clinical trial studying topical timolol solution for cutaneous hemangiomas is currently underway. At the 35th annual meeting of the Society for Pediatric Dermatology, the promising, although not universal, success of topical timolol gel for periocular hemangiomas was discussed. I suspect that thickness, depth, and extent of the hemangioma and limitations of percutaneous drug absorption may influence the efficacy of topical beta-blocker therapy. However, a subset of thin hemangiomas may prove to respond beautifully, as in this case report. The results of these studies will be highly anticipated.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology March 26, 2010

Citation(s):

Guo S and Ni N. Topical treatment for capillary hemangioma of the eyelid using β-blocker solution. Arch Ophthalmol 2010 Feb; 128:255.

• Medline abstract (Free)

Abstracts from the 2009 annual meeting of the Society for Pediatric Dermatology. Pediatr Dermatol 2009 Sep/Oct; 26:645.

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