Treatment

In most cases, infantile hemangiomas do not require therapy unless they are causing complications. The choice of treatment may be based on the age of the patient, as well as the size, depth, and stage of the hemangioma.4,7 The treatments currently used for infantile hemangiomas are propranolol, off-label medications, laser therapy, and surgery.1,3 Oral propranolol is now approved by the US Food and Drug Administration as a treatment for infantile hemangiomas and may work more quickly than steroids.2,8 It is important to try to treat complicated infantile hemangiomas during the proliferative phase to prevent expansion and allow regression to take place.5 

Beta-blockers, such as propranolol, are used to treat infantile hemangiomas and have been shown to stop expansion and result in regression of the lesions.1,5 Oral propranolol can lead to involutional changes in skin infantile hemangiomas and can alleviate stridor due to airway hemangiomas. In some cases, skin infantile hemangiomas may fully involute within 6 months of propranolol use.5 Propranolol may cause severe side effects, such as bradycardia and hypoglycemia.1,3 Therefore, it is best to administer propranolol when an infant feeds, and it is important for caregivers to be aware of indications of hypoglycemia in infants and know how to respond.3 A cardiology consult should be obtained and the patient’s electrocardiogram, vital signs, and serum glucose level should be evaluated before beta-blockers are administered to determine if they are appropriate for the patient.7 Topical beta-blockers can also be used for superficial cutaneous infantile hemangiomas. In particular, topical timolol appears to be helpful in resolving some small skin infantile hemangiomas by decreasing erythema and causing involution.5,8 Although timolol is recommended for some patients with cutaneous infantile hemangiomas, the safety of its use over time for this condition is still not fully known, and therefore caution is advised.5


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Before oral propranolol, oral corticosteroids were commonly used to treat infantile hemangiomas. Corticosteroids help to prevent infantile hemangiomas from expanding but may not lead to full involutional changes.1,5 Corticosteroids also cause side effects, such as cushingoid characteristics, stunted growth, and immune system suppression, which may increase the risk for infections.3,7 Often, growth that is lost during corticosteroid treatment is regained once the corticosteroids are stopped.3 Intralesional corticosteroids have been used to treat infantile hemangiomas on the head and neck, and topical corticosteroids have been administered for localized superficial hemangiomas.6 

Vincristine has been used to treat infantile hemangiomas unresponsive to corticosteroid treatment.3,7 Propranolol is a more common drug of choice for infantile hemangiomas than vincristine; however, vincristine is preferred to interferon alfa.7 Side effects of vincristine are constipation, pain in the abdominal region, and foot drop due to toxic effects of the drug on the nervous system.1,3

Interferon alfa has been used to treat infantile hemangiomas; however, it has severe side effects, such as neurotoxicity and spastic diplegia.3,4 Recommendations in the literature regarding the use of interferon alfa for infantile hemangiomas are variable. Some authors recommend interferon alfa for infants older than 1 year with infantile hemangiomas that are potentially fatal or unresponsive to treatment and who receive close neurological monitoring, whereas others advise against the use of interferon alfa for infantile hemangiomas.1,3,4,7

Pulsed dye laser is the most frequently used laser for treating infantile hemangiomas, especially those that ulcerate.3,4,8 This laser therapy is used to treat superficial infantile hemangiomas, and multiple treatments may be required.4,7 Pulsed dye laser may diminish the pain caused by ulcerated infantile hemangiomas.3 However, scars, hypopigmented skin, and even ulcers may result from pulsed dye laser treatment.1,3,4

Surgery is a useful therapy for deep infantile hemangiomas and can remove excess fibrofatty tissue and scarring.1,4 A risk of surgery is bleeding; however, new techniques may prevent this complication.7 Surgery can also treat infantile hemangiomas if drug therapy is unsuccessful or the infantile hemangioma is potentially fatal or deforming. Surgery is used to treat airway and periorbital hemangiomas.3,7 

Conclusions

Infantile hemangiomas are benign lesions that commonly affect children and are generally diagnosed based on clinical findings. They are often found on the head and neck. Many of them resolve without treatment; however, complications may arise, including ulcers, infections, bleeding, visual problems, difficulty breathing, and visceral issues. Depending on the complication, propranolol, corticosteroids, vincristine, interferon alfa, laser therapy, and surgery may be therapeutic options.

Sarah Lund is a medical student at the University of Texas Medical School at Houston, and Maura Holcomb, MD, is a resident at the Baylor College of Medicine in Houston.

References

  1. Holland KE, Drolet BA. Infantile hemangioma. Pediatr Clin North Am. 2010;57(5):1069-1083. 
  2. Hartzell LD, Buckmiller LM. Current management of infantile hemangiomas and their common associated conditions. Otolaryngol Clin North Am. 2012;45(3):545-556. 
  3. Kwon EK, Seefeldt M, Drolet BA. Infantile hemangiomas. Am J Clin Dermatol. 2013;14(2):111-123.
  4. Callahan AB, Yoon MK. Infantile hemangiomas: a review. Saudi J Ophthalmol. 2012;26(3):283-291. 
  5. Lee KC, Bercovitch L. Update on infantile hemangiomas. Semin Perinatol. 2013;37(1):49-58.
  6. Craiglow BG, Antaya RJ. Management of infantile hemangiomas: current and potential pharmacotherapeutic approaches. Paediatr Drugs. 2013;15(2):133-138. 
  7. Fay A, Nguyen J, Waner M, Conceptual approach to the management of infantile hemangiomas. J Pediatr. 2010;157(6):881-888.
  8. Reddy KK. Management of infantile hemangiomas. J Cutan Aesthet Surg. 2014;7(2):85-86.