Propranolol as First-Line Treatment for Infantile Hemangiomas

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Sir: We read with great interest the article on the classification of vascular anomalies and the comprehensive treatment of hemangiomas.1 We are all too aware of the difficulties of treating hemangiomas, such as the timing and duration of intervention, and the inadequacy of conventional therapies. The article clearly demonstrates the side effects of the pharmacologic treatments for hemangiomas and the need for newer treatment options. Recently, a number of cases have been reported of the efficacy of β-blockers in the treatment of hemangioma.2,3 As part of a larger study, we have used propranolol in a total of 15 patients. So far, we have observed signs of rapid involution of hemangioma within the first week of treatment in all patients (Fig. 1). The response rate is faster than those we have seen when corticosteroids are used. In addition to stopping the proliferation of hemangiomas, propranolol also causes rapid involution within a short period. We now offer propranolol as a first-line treatment to all rapidly proliferating hemangiomas with functional deficit and/or disfigurement. We have developed a treatment protocol in conjunction with the cardiologist that involves pretreatment cardiac workup and an in-hospital titration of propranolol up to 1 mg/kg three times per day.4 So far, we have not needed to increase the dosage to more than 1 mg/kg three times per day.Fig. 1.: Ulcerating perineal hemangioma before (above) and 48 hours after (below) treatment with propranolol 1 mg/kg three times per day. The patient's pain score had decreased significantly.All patients have responded well to treatment, with no side effects. Although we agree with all the points raised in the thorough article by Burns et al., we would like to suggest that β-blocking agents have an important role in the management of infantile hemangioma. Will J. M. Holmes, M.R.C.S. Anuj Mishra, M.R.C.S. Cath Gorst, R.G.N., R.S.C.N. Se-Hwang Liew, F.R.C.S. Department of Plastic and Reconstructive Surgery Alder Hey Children's Hospital Liverpool, United Kingdom