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Immunosuppressive Effects of Corticosteroids for Infantile Hemangioma

Postpone live vaccines and check antibody titers when administering corticosteroids for hemangiomas.

Most infantile hemangiomas (IHs) require only watchful waiting, but when complications such as impairment of vision, ulceration, airway compromise, or disfigurement are present, intervention is required. Systemic corticosteroids are the mainstay of therapy, but prospective studies evaluating their immunosuppressive effects have been lacking.

Investigators at a children's hospital prospectively studied 16 infants (13 girls; mean age, 2.9 months) who required corticosteroid therapy for IH.

The prednisolone dose was 2.5 mg/kg/day by mouth, which was increased to 3 mg/kg/day if response was poor. The duration of therapy ranged from 8 to 32 weeks (mean, 22 weeks). Standard immunizations were given on schedule.

Corticosteroid-associated effects included increased appetite (69%), slowing of linear growth velocity (62%), gastrointestinal irritation (62%), irritability (56%), and hypertension (12%). No intercurrent infections occurred. The numbers of all B- and T-lymphocyte subpopulations decreased significantly after corticosteroid administration. Compared with baseline, numbers of CD19– B lymphocytes and CD4+ T cells were significantly reduced at 8 weeks of therapy, as were CD8+ T cells at week 16. All lymphocyte subpopulations normalized within 3 months after the end of corticosteroid therapy. At 3 months post–corticosteroid therapy, only 5 of 16 patients had protective antibody levels to tetanus, and 13 of 16 had protective levels to diphtheria.

The authors recommend Pneumocystis carinii pneumonia (PCP) prophylaxis with trimethoprim (TMP)-sulfa during treatment if corticosteroids are given for 2 or more months, and they advise that antibody titers be checked after therapy to assess the need for booster immunizations.

Comment: We must respect the immunosuppressive effects of corticosteroids. The authors' recommendations are sound. TMP-sulfa prophylaxis is warranted, as three cases of Pneumocystis carinii (jiroveci) pneumonia have been reported in infants treated with corticosteroids for hemangiomas. Live vaccines should be postponed until after recovery from corticosteroid therapy. In addition, antibody titers should be checked by the pediatrician and booster immunizations given accordingly. My additional suggestion is that an endocrinology consultation for adrenal insufficiency be considered after therapy as well. Propranolol, which lacks such risks, is undergoing study for IH treatment and may eventually supersede corticosteroids as first-line therapy.

— Mary Wu Chang, MD

Published in Journal Watch Dermatology June 18, 2010

Citation(s):

Kelly ME et al. Immunosuppressive effects in infants treated with corticosteroids for infantile hemangiomas. Arch Dermatol 2010 May 17; [e-pub ahead of print]. (http://dx.doi.org/10.1001/archdermatol.2010.90)

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