PA28 Case series of concomitant use of propranolol and prednisolone in the treatment of ulcerated infantile haemangiomas and an updated literature review

Abstract

Abstract Infantile haemangiomas (IHs) are the most common benign tumours of infancy. Ten per cent of patients suffer complications, including ulceration, bleeding and functional impairment, and systemic treatment is required to reduce permanent disfigurement. Prednisolone was once the most commonly used and most efficacious treatment modality for complicated IHs, but propranolol has since overtaken its role as the first-line therapy in the last decade. In our practice, we have seen that propranolol monotherapy may not be sufficient in cases of IH with complex ulceration, and oral corticosteroids may serve as an effective adjunct in managing this group of patients. We present a case series of all patients diagnosed with ulcerated IH at KK Women’s and Children’s Hospital over the last 10 years. Fifteen patients were found to have ulcerated IHs. Eight patients were treated with both oral propranolol and oral prednisolone, and four patients were treated with oral propranolol alone. Patients were initiated on propranolol 1–2 mg kg−1 daily, and this dosage was titrated over an average of 9.6 months. Patients prescribed prednisolone had a tapering dosage starting from 0.5–2 mg kg−1 daily for 8–36 days. Average time to complete healing of ulcerated IHs in patients treated with both prednisolone and propranolol was 27.1 days, while patients treated with propranolol alone took 34 days. One patient had recurrence of ulceration after 2 months and had a second, 9-day course of prednisolone. None of the patients had complications from propranolol or prednisolone. Ulceration—the most common complication of IH—tends to heal poorly and is associated with pain, bleeding, infection and scarring. Early and efficacious treatment is needed to prevent functional impairment and permanent disfigurement. Several cases of ulcerated IH have been observed to be recalcitrant to propranolol monotherapy. In these patients, prednisolone used as an adjunct to propranolol has resulted in accelerated healing of these ulcerations. There are no guidelines on the dose and duration of prednisolone use, although a tapering dose starting at 1 mg kg−1 daily is usually given until complete healing of ulceration.