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Original Article

Oral Propranolol for Treatment ofPediatric

CapillaryHemangiomas

Maryam Aletaha, MD; Hossein Salour, MD; AbbasBagheri, MD Nasrin Raffati, MD; Nassim

Amouhashemi, MD

Ophthalmic Research Center, Shahid Beheshti University of MedicalSciences, Tehran, Iran

Purpose: To report the long-term results of treatment of pediatric capillaryhemangiomas with oral propranolol.Methods: Three infants, 3 to 4 months of age, with periocular capillaryhemangiomas were treated with oral propranolol solution (Inderal,20mg/5ml) 2-3 mg/kg per day divided in 2 doses. Propranolol wascontinued up to the end of the first year of life and tapered over 2-3weeks. All infants were followed for 20 months. Lesion size and evolutionwere assessed during the follow-up period.Results: Significant improvement was noted in all patients in the first 2months of therapy with slow and continuous effect throughout the follow-up period. No serious complications were observed.Conclusion: Oral propranolol can be used as a first line agent in

children with capillary hemangiomas.

Keywords: Oral Propranolol; Capillary

Hemangioma

J Ophthalmic Vis Res 2012; 7 (2): 130-133.

Correspondence to: Maryam Aletaha, MD. Assistant Professor of Ophthalmology; OphthalmicResearch Center,#23 Paidarfard St., Boostan 9 St., Pasdaran, Tehran 16666, Iran; Tel: +98 21 2258 5952, Fax:+98 21 2259 0607;e-mail: maryamaletaha@yahoo.com

Received: September 20, 2011 Accepted:January 14, 2012

INTRODUCTION

Capillary hemangiomas account for 8-10% of benign pediatric tumors.1

Treatment is necessary when ulceration,facial disfigurement and risk of amblyopiais present. Corticosteroids, in variousforms are the mainstay of treatment.Local injection of corticosteroids is themost common route of administration;howeve it is associated with seriousadverse effects such as occlusion of theophthalmic artery or central retinal vein,retinal embolization, adrenalsuppression and hypopigmentation at thesite of injection. Topical application ofcorticosteroids has been used for

superficial lesions only.2 Unfortunately,well- designed studies that demonstratethe efficacy of corticosteroids are scarceand the response to this therapy, whichcan be accompanied by grave side-effects, is unpredictable.3 Othersystemic

mailto:maryamaletaha@yahoo.commailto:maryamaletaha@yahoo.com

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drugs such as vincristine, alpha-interferon and cyclophosphamide mayalso entail significant adverse effects.2,4

There are limited studies on theduration, long-term effects andcomplications of propranolol therapy forcapillary hemangiomas and to the best of

our knowledge, propranolol is arelatively safe drug for use in youngpatients.5-16 Herein, we report the long-term results of oral propranolol on

congenital capillary hemangiomas inthree patients.

METHODS

W e d e s c r i be thr e e i nf a n ts w i thc o n ge n i ta l capillary hemangiomas

who received treatment from the age of3-4 months up to the end of the firstyear of life. The study was approved bythe Ethics Committee of theOphthalmic

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Propranolol for Pediatric Hemangiomas;Aletaha et al

Research Center at Shahid BeheshtiUniversity of Medical Sciences.Informed consent was obtained fromthe patients guardians prior to the

study. All patients were admitted andmonitored for 3 days, and underwent acomplete baseline ophthalmicexamination. Laboratory studiesincluding complete blood count, bloodurea nitrogen (BUN), serum creatinine,blood s ugar, s odium and potas siumlevels were performed at the beginningof the study. All cases underwentexamination and baselineechocardiography by a pediatric

cardiologist.Treatment was initiated at a

dose of1mg/kg/day propranolol solution(Inderal20mg/5ml) on the first day; if vitalsigns andblood sugar were stable the dose wasdoubledon the following day. The maintenancedose was

1-2mg/kg/day divided in two doses.Patients were fed 2 to 3 hours afteradministration of propranolol. They werefollowed twice a week for 2 months and

then monthly for 20 months. If no furtherbenefit was observed during follow- up,propranolol was tapered over 2-3 weeks.Cases 1 and 2 are described together dueto similarity and case 3 is describedseparately.

RESULTS

Cases 1

and 2

Cases 1 and 2 were three and four-month-old female infants with upper lidhemangiomas causing complete ptosisand eyelid fissure closure (Fig. 1).Perinatal history was unremarkable

Before Treatment

(0)After Treatment (2 weeks) After Treatment (3 months) After Treatment (24

months)

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Case

3

Case

2

Case

1

Figure 1. Photographs of 3 patients with eyelid capillary hemangiomas before and after treatment with

propranolol.

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Propranolol for Pediatric Hemangiomas;Aletaha et al

and no systemic disorders were present.The hemangiomas were red lobulatedlesions which faded slightly on diascopy.Examination of the orbits revealed no

abnormality. Two weeks after treatmentthe lesions regressed by 30% and thepatients were able to open their eyes.By the end of the second month, thelesions had been reduced to one-third oftheir original size.

Propranolol was continued in bothchildren until one year of age after whichit was discontinued gradually. In case #2,propranolol was discontinued by theparents for two weeks resulting in

regrowth of the tumor. Propranolol wasreinitiated and the lesion responded totreatment without any problem.

Case3

This patient was a three-month-oldfemale infant with a massive lesion onthe left side of her face which includedthe eye and ear. Ulceration of the lesionhad led to upper lid margin necrosis andptosis with the risk of deprivationamblyopia. She was treated with oralpropranolol and the lesion regressed tonearly half of its visible size over onemonth. After one year, propranolol wastapered over a period of 2-3 weeks (Fig.1).

DISCUSSION

Capillary hemangiomas are commonchildhood tumors reaching theirmaximum growth in the first year oflife.1-5 Complete spontaneous regressionof the tumor occurs in 32-60% of patients by the age of four and in 72-76% by the age of seven years. Due tothis long period for spontaneousresolution, there is a possibility ofamblyopia due to axial myopiasecondary to ptosis or astigmatism inwhich the positive axis lies parallel to themass. Amblyopia occurs in 44-64% ofcases due to anisometropia or visual

deprivation.

11-14

Additionally, massivehemangiomas alter skin structure bystretching or injury to the surfacetexture, and may cause disfigurement.12-16 Our patients were treated for one ofthese indications.

There are some reports on thedramatic effect of oral propranolol on the

size and volume

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of vascular masses5-16 which wasreplicated in our patients as well. It isinteresting that the first visible andmeasurable response to treatment wasobserved within 48 hours of initiatingtreatment in superficial cases. Lesion sizedecreased to half of its original size after

2 months. This rapid response, ascompared to corticosteroid-basedtreatments14, is especially valuable interms of preventing amblyopia.

Beneficial effects of propranolol areprobably due to reduction of theexpression of genes for vascularendothelial growth factor, basicfibroblast growth factor and matrixmetalloproteinase 9, in addition toinduction of apoptosis in capillary

endothelial cells.3

Bradycardia and hypotension arethe most common side effects ofpropranolol.5-6

Propranolol induced hypoglycemia orthe masking of its symptoms areparticularly important in children; thesemay be easily diagnosed and treated byemploying the precautions mentioned inour study and other reports.5-9 History ofprematurity, age less than

3 months, comorbidities, and asthma arefactors associated with a higher risk ofside effects.3

Wheezing15 and hyperkalemia16 have alsobeen reported.

During the follow-up period and afterdiscontinuation of treatment we observed

no complications, tumor regrowth, orgeneral growth impairment in our cases.None of our patients developedanisometropia or obstruction of the visualaxis. Compared to other published reportson treatment of capillary hemangiomaswith propranolol, our cases had longerduration of follow-up.1-16

Based on the good results and a lowrisk profile, we recommend propranololas a safe and effective first line therapy

for capillary hemangiomas in children. Arandomized clinical trial could enrich theexisting knowledge and improve themanagement of periocular and orbitalhemangiomas. Further research shouldfocus on management of older subjectswith aesthetic issues.

Conflicts ofInterest

None.

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