Many hemangiomas, even with rapid growth, stay relatively small and cause no problems. Since they will eventually resolve, no treatment is needed. A significant minority of hemangiomas cause functional problems or threaten to leave permanent skin changes and require active treatment. Early in life, when hemangiomas have their greatest growth potential, it can be difficult to determine how big they will become, so your child may need to be seen in the clinic more often; as they get older this will be less often.
Reasons for treatment include: ulceration (breakdown of the skin), effect on important structures such as the eye, lip, or nose, psychosocial concerns, or when a hemangioma is so large or growing so rapidly that there is a real risk of leaving permanent scarring.
A beta-blocker which is licensed as an eye drop for treating glaucoma. It has been shown to be effective in treating hemangiomas that are relatively flat, either because they have not yet thickened or because they have never grown to be thick. Potential known side effects include skin irritation; it should be avoided in ulcerated hemangiomas or in larger areas of skin as there may be systemic absorption.
Small amount of steroids may be injected directly into hemangiomas – often one or two treatments at 3 to 4 week intervals. This form of treatment is typically used for small hemangiomas (1-3 cm) on the face. The main potential side effects are skin atrophy (thinning) or systemic absorption.
Clobetasol, a strong steroid ointment, applied 2x/day can be used to treat relatively flat hemangiomas, particularly if they are not becoming thick during the growth phase. The main potential side effects are skin atrophy (thinning) or systemic absorption.
SYSTEMIC (INTERNAL) TREATMENTS
Some hemangiomas require systemic (internal) treatment to prevent complications caused by the hemangioma. Large hemangiomas on the eyelids, lip, nose, or airway need to be treated with systemic treatment. If there are sores (ulcers) in the hemangioma, systemic treatment can also help these heal faster. Hemangiomas that have a risk of permanent scarring should also be treated. Systemic treatments include propranolol and corticosteroids like prednisolone.
The use of propranolol for hemangiomas was first reported in 2008. Propranolol (Hemangeol) is the only FDA-approved medication for the treatment of infantile hemangiomas. It was approved in March 2014 after a large study showed that it was both effective and safe. Propranolol is a “beta-receptor blocker” that is also used to treat high blood pressure, irregular heart rate and migraine headaches.
We do not completely understand how propranolol makes hemangiomas shrink. Propranolol seems to slow the growth of hemangioma cells and shrink blood vessels so that the size of the hemangioma is reduced over time. Propranolol usually takes effect quickly. Most patients show some improvement in the first few days to weeks on the medication. Almost all patients (90-95%) improve with propranolol.
All patients should have a complete evaluation (including a medical history, family history and physical exam) with a medical provider before starting propranolol. Some children may need to have tests done to make sure that they can take propranolol safely. These tests may evaluate the heart, circulation or brain. Speak with your child’s provider about whether tests are needed.
Potential side effects of propranolol include: wheezing, sleep disruption, diarrhea, vomiting, constipation, and rarely low blood sugar, slowing of the heart rate, low blood pressure, allergic reaction.
This is caused by narrowing of the airways and usually happens when the child has a respiratory viral illness. If your child is wheezing, contact your provider. Usually it is safest to stop the propranolol while your child is sick and restart it once your child is better.
Change in Sleep Pattern
Propranolol can affect some children's sleep pattern. Children may have a hard time falling asleep, or may sleep more than normal. This is most noticeable when propranolol is first started. Night terrors (bad nightmares) are less common. Sometimes it can help to give the last dose of propranolol earlier in the day. If these changes do not get better with time, or are severe, report them to your doctor.
Gastrointestinal side effects
Diarrhea, vomiting (reflux) and constipation are all reported in patients taking propranolol. Usually these side effects are not severe and get better with time.
Slow Heart Rate (Bradycardia)
Propranolol can make the heart rate slower, but most of the time the heart rate in infants taking propranolol for hemangiomas is still in a normal and safe range.
Low Blood Sugar (Hypoglycemia)
Very rarely propranolol can contribute to low blood sugar. Low blood sugar can cause drowsiness or rarely seizures. Coldness, shakiness, and sweating are early signs of low blood sugar. Your child is more likely to have low blood sugar if she or he is not eating normal amounts or has gone for several hours without eating. You can prevent low blood sugar by giving propranolol during a feed or right after your child has eaten. If your child is sick and not eating normally, talk to your provider about stopping the propranolol until your child is eating normally again.
As with any medicine, people can be allergic to propranolol, though this is very rare. You should stop your child's medicine and call your doctor if you think your child may have an allergic reaction. Signs of an allergic reaction may be hives, swelling of the face/hands/lips, and difficulty breathing or swallowing. This type of reaction typically appears within an hour of being given the medication.
Other Possible Side Effects
Propranolol can much more rarely cause other side effects. If your child has a new problem or change in behavior, contact your pediatrician or the doctor prescribing the propranolol to see if it might be related.
OTHER MEDICINES AND PROPRANOLOL
Propranolol may interact with some other drugs (over the counter, herbal and prescription). Check all medicines that your child is taking with your child's doctor or pharmacist.
HOW IS PROPRANOLOL TAKEN?
Propranolol is available in a liquid that is taken by mouth. It is typically given 2 or 3 times per day. It is important to carefully measure the dose with a syringe to make sure the correct dose is given. Your provider will tell you how the doses should be spaced out throughout the day. To avoid confusion around whether or not the medication has been given, it may be better to have the same person give the propranolol.
WHAT CAN I EXPECT WHILE MY CHILD IS TAKING PROPRANOLOL? HOW LONG IS THE TREATMENT COURSE?
Propranolol may begin to change the color and reduce the size of your child’s hemangioma within a few weeks. If the hemangioma is not responding, your doctor may increase the dose if it is still in a safe range. Most infants who need propranolol are on it for several months to a year. How long your child takes propranolol depends on the type of hemangioma, the complications the hemangioma is causing and the age of the child when treatment was started. If propranolol is stopped too soon, the hemangioma may begin to grow again and the medication may need to be restarted. Many infants will stay on the propranolol until they are 12 to 15 months of age. At this age there is less risk of the hemangioma growing back when the propranolol is stopped.
ORAL CORTICOSTEROIDS (PREDNISOLONE)
Before oral propranolol (beta-receptor blocker) was used to treat hemangiomas, oral corticosteroids (prednisolone) were used to treat hemangiomas that needed treatment. Although steroids can slow the growth of infantile hemangiomas, they have side effects with long term use. These side effect can include: immune suppression, growth issues, and high blood pressure. Similar to propranolol, oral corticosteroids are given for several months and the dosage is gradually reduced toward the end of treatment.
Studies comparing propranolol and oral corticosteroids have shown that both treatments are effective in treating infantile hemangiomas. However, propranolol is more effective in reducing the size of infantile hemangiomas with fewer side effects.
Although propranolol is now considered first line treatment for complicated infantile hemangiomas, oral corticosteroids are still being used in certain situations. Oral corticosteroids may be used if propranolol cannot be used, for example if a child is allergic to propranolol or has a heart or lung condition that prevents the safe use of propranolol, or if your child cannot tolerate propranolol. Your provider may also consider treatment with oral corticosteroids if your child’s hemangioma is not responding to propranolol. A combination of both propranolol and oral corticosteroids may also be considered for severe, life threatening infantile hemangiomas.
A laser is a very selective light which is absorbed by the red cells within the hemangioma, creating heat and destruction of blood vessels. Pulsed dye laser is preferentially used, and is quite safe. However, it is not an “eraser” and multiple treatments are typically required to lighten a hemangioma more quickly than expected without treatment. Pulsed dye laser is usually not first line therapy and if used should be combined with other therapies. It only penetrates a millimeter into the skin, and is really of limited benefit in preventing the hemangioma from growing. Pulsed dye laser can be used to improve an infantile hemangioma which is purely superficial, but does not help or prevent a deeper component. There is a small risk of pigmentary change which often resolves with time, and rarely scarring and atrophy. It should be avoided during the rapid growth phase as it does have the potential to cause ulceration. Other drawbacks are that it is moderately painful and costly, and is not always covered by insurance.
Despite these limitations, pulsed dye laser can be beneficial especially when combined with other therapies in certain cases. It is helpful in "mopping up" the small blood vessels that can remain on the surface of the skin after successful treatment with propranolol or timolol or that persist after spontaneous involution. It can also be used to help ulcerated hemangiomas heal more quickly as well as later help any remaining small blood vessels.
Excisional surgery always leaves some degree of permanent scarring, and this needs to be considered in deciding whether to operate. Excisional surgery may be necessary after a hemangioma has largely resolved if there is permanent distortion or significant scar. Previously some hemangiomas needed surgery even earlier in life, however now with better medical treatment, surgery can often be avoided. Reasons to treat with surgery include:
Hemangiomas which are ulcerated and painful and not responding to wound care and medical therapy.
Hemangiomas which are mushroom-like or thick and sticking out above the normal skin may need surgical correction eventually, so early surgery may be considered, especially if they are not responding to medical therapy.
Involuted or nearly involuted hemangiomas which are leaving distortion of the skin or scarring. We like to operate on these children after age 3 but ideally before age 5 when children have increased body awareness and start elementary school.