Topical timolol maleate may be a well-tolerated and effective alternative to oral propranolol for infantile hemangiomas, especially thin, superficial hemangiomas, according to research published in Pediatrics.

The findings are based on a multicenter, retrospective cohort study of 731 patients who were treated with topical timolol at 9 centers. Katherine Püttgen, MD, from the Johns Hopkins School of Medicine in Baltimore, and colleagues analyzed infantile hemangiomas that were suitable for timolol, according to the treating clinician, as well as clinical details of the cases including photographs. The primary outcome measures were efficacy as assessed with use of visual analog scales for color and for size, extent, and volume based on a review of digital photographs that were taken as standard of care.

The researchers found that 80.1% of infantile hemangiomas were localized, and 55.3% were superficial. The risk of disfigurement was the most frequent indication for therapy (74.3%). Significant predictors of response included duration of therapy, initial thinness, and hemangioma subtype. The best response, according to the investigators, was for superficial infantile hemangiomas that were <1 mm thick. Fifty-three (7.3%) cases required subsequent therapy with a systemic β-blocker. Adverse events were mild, occurring in 25 (3.4%) patients, and no cardiovascular side effects were reported.

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“[Clinicians] caring for infants with infantile hemangiomas must be mindful of the nonlinear infantile hemangioma growth trajectory to determine whether watchful waiting, topical timolol maleate, or systemic therapy is indicated,” stated Dr Püttgen’s group. “Young infants with infantile hemangiomas, particularly infants aged <3 months, have a high risk of accelerated hemangioma growth that can potentially result in permanent and disfiguring scarring. In preselected patients with smaller and relatively superficial infantile hemangiomas, topical timolol maleate seems to be a safe and effective therapy to help control infantile hemangioma growth and accelerate involution.

“Parents should be advised to contact their [clinician] if rapid growth occurs despite topical treatment because transition to systemic therapy may be more appropriate in some cases,” the researchers concluded. “Topical timolol maleate can be recommended as an initial, and often sole, treatment modality for many relatively superficial infantile hemangiomas without aggressive growth or threat of functional impairment.”


Püttgen K, Lucky A, Adams D,  et al. Topical timolol maleate treatment of infantile hemangiomas. Pediatrics. 2016;138(3). doi: 10.1542/peds.2016-0355.