Propranolol Treatment for Infantile Hemangiomas

The best thing about being a nurse is that you are always learning something new! As a dermatology nurse, I had the privilege of working with a pediatric dermatologist. I still remember walking into my first pediatric dermatology case. The patient was an infant with a pea-size hemangioma near the right eyelid. I listened to the doctor's explanation of the diagnosis and treatment options. It surprised me that propranolol was a treatment choice for infantile hemangiomas.

What Are Infantile Hemangiomas?

Infantile hemangiomas are noncancerous growths formed by blood vessels. These lesions can present at birth or develop over the first weeks of life. Hemangiomas can appear on the head and scalp and anywhere on the body. They are more commonly seen in infants that are females than males, premature, low birth weight, fair-skinned, with family history, and complications during pregnancy.

Signs and Symptoms

The lesion may be first noted at birth or develop within weeks after birth. Infantile hemangiomas follow a growth pattern. The first stage is the emerging phase, in which the lesion begins to present itself from birth to three months of age. Families describe the lesion starting as a dot or bruise-like mark. The next stage is the growth phase which can last from 6 months to 10 months of age. The last stage is involution. During this stage, the lesion shrinks and lightens in color. This stage can last anywhere from infancy to 10 years of age. Hemangiomas can be superficial or deep. The superficial hemangiomas are red and appear on the surface of the skin. They are also known as "strawberry birthmarks." Deep hemangiomas are under the skin and can look blue or skin-colored.

Local Treatments

Not all hemangiomas need treatment since some can shrink in size during the involution stage. Providers may want to monitor the lesion as long as it does not interfere with the patient's activities of daily living.

Some factors the dermatologist may consider for treatment

• baby's age
• location
• size of the hemangioma
• growth rate of the lesion
• problems such as ulcerations (skin openings)

Also, the doctor may order blood work or additional testing to rule out any contraindications. Providers can prescribe topicals for treatment. Timolol is a beta-blocker in the formulation of eye drops but is applied directly to the lesion. Topical steroids, such as clobetasol, is another option as well. These medications are to treat hemangiomas that are smaller in size and have a flat surface. Injection treatments such as intralesional steroids are typically for smaller hemangiomas (1-3 cm). The potential side effect of prolonged use of steroids can cause skin atrophy (thinning).

Treatment with Propranolol

Propranolol is a beta-blocker used to treat blood pressure and other medical conditions. Propranolol helps to constrict the blood vessels to reduce the growth of the hemangioma. The course of treatment can range from 6 to 12 months. Propranolol is administered twice daily (8 hours apart) during or after a meal. The medication comes in a liquid form taken by mouth. The patient's weight determines the dosage; thus, families need to update their child's dermatologist if there is a weight change.

Side effects to be aware of when an infant takes propranolol

• unusual sleepiness
• low blood sugar
• restlessness
• irregular heartbeat
• low blood pressure
• breathing problems or wheezing

The patient can initiate propranolol both in an outpatient or inpatient setting. The parent or guardian is to feed the infant before giving the medication. After administering the drug, the healthcare team will monitor the patient to make sure side effects do not occur while checking vital signs every hour. Educating families on medication administration and side effects is completed before discharge.

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References/Resources

Hemangiomas: UChicago Medicine

Hemangioma FAQs: Hemangioma Investigator Group (HIG)

Hemangioma Treatment: Hemangioma Investigator Group (HIG)

Infantile Hemangioma: Johns Hopkins Medicine

Hemangiomas (for Parents): Nemours Children's Health

Propranolol (Infantile Hemangioma): MedlinePlus