Infantile Hemangioma Medication

  • Author: Richard J Antaya, MD; Chief Editor: William D James, MD   more...
 
Updated: Jan 11, 2012
 

Medication Summary

The goals of pharmacotherapy for infantile hemangiomas are to reduce morbidity and mortality and to prevent complications. Note that none of the treatments is approved for treatment of infantile hemangiomas by the US Food and Drug Administration, and all therapies should be considered off-label usage.

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Corticosteroids

Class Summary

Oral and intralesional corticosteroids are effective at slowing the growth and decreasing the size of proliferating infantile hemangiomas. The mechanism of action has not been elucidated completely; however, corticosteroids have been shown to inhibit VEGF-A expression and subsequent proliferation in hemangioma stem cells in a murine hemangioma model.[55] Evidence indicates that corticosteroids block estradiol receptors in hemangiomas in vitro. Response vary widely, from less than 40% to greater than 90%, depending on dose, duration of treatment, and age at which corticosteroid therapy is initiated.[56] Corticosteroid therapy should be administered during the proliferative phase because it has a negligible effect on involuting and otherwise stable infantile hemangiomas. The oral route generally is preferred over intralesional therapy; however, the location, size, patient age, and physician experience factor into the decision-making process.

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Prednisolone (Prelone Syrup, Pediapred Oral Solution, Delta-Cortef, OraPred)

 

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

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Beta-adrenergic Blocker

Class Summary

Beta-blockers, most specifically propranolol and more recently topical timolol, have been in use since mid 2008 for infants with severe or disfiguring hemangiomas.[57, 58] Several reports in the literature describe efficacy for life- and sight-threatening airway and retro-orbital hemangiomas, respectively.[42, 59, 60] Some have been treated with the beta-1 selective blocker, acebutolol. However, most infants reported have been treated with the nonselective blocker, propranolol, at a dose of 2-3 mg/kg/d in 2-3 divided doses. Duration of therapy varies from 2-10 months. As early as 24 hours after the initiation of therapy, many infantile hemangiomas have begun to change from intense red to purple, with evidence of softening. Most continue to improve until nearly flat and with significantly diminished color.

A retrospective study of 39 children in France with infantile hemangiomas of the head and neck concluded that propranolol treatment effectively lightened and reduced hemangiomas, especially as first-line treatment started during proliferative growth (mean age, 4.1 m; mean duration, 8.5 m).[61] Of 37 hemangiomas successfully treated with propranolol, 26 were in locations (parotid area, lips, or nose) where the authors would not have initiated corticosteroid therapy.

The mechanism of action is unknown; however, some hypothesize that local vasoconstriction may be a factor, which is based on the early color change and softening of the lesion. One study has demonstrated that nonspecific and beta2-selective blockers (eg, propranolol) triggered apoptosis of capillary endothelial cells in adult rat lung tissue, suggesting a similar mechanism may be plausible for hemangioma endothelial cells.[62]

No protocol for initiating propranolol therapy in infants with hemangiomas is universally accepted.[63] Therapy should be approached with extreme caution in neonates and infants who generally do not have preexisting venous hypertension or any other hemodynamic disorder. Of particular note, infants with hemangiomas associated with PHACE syndrome with cerebrovascular anomalies are at higher risk for cerebral vascular accidents and therefore should not receive beta-blockers.

Provisional guidelines for initiation

Pretreatment

Exclude infants with evidence of the following:

  • Bronchospasm
  • Cardiac disease
  • CNS vascular anomalies (suspected PHACE syndrome, large cervicofacial hemangiomas [see Mortality/Morbidity for PHACE syndrome definition]

Baseline laboratory tests and evaluation include the following:

  • Blood glucose level
  • Blood pressure check
  • Electrocardiography (variable)
  • Echocardiogram (if considering PHACE syndrome or other clinical indications)
  • Pediatric cardiology consultation for evaluation and dosing recommendations (if any concerning findings)

Dosing - See below

Monitoring

Initially in the hospital (whether in or out of intensive care unit, cardiac care unit, or monitored bed), monitor for 24-72 hours; practices vary considerably.

Monitoring 1 hour after administration (dosing) includes the following:

  • Blood pressure check
  • Heart rate check (hold dose for heart rate at < 100 beats per min)
  • Blood glucose level (due to potential blocking of liver glycogen phosphorylase): Recommended that young infants feed every 3-4 hours to decrease risk of hypoglycemia.
  • Temperature determination to evaluate for hypothermia
  • Observation for bronchospasm

At home, parents should observe for signs of lethargy, poor feeding, and/or bronchospasm.

Blood pressure and heart rate should be evaluated intermittently at the pediatrician's office.

Discontinuation

Consider gradual taper over 2 weeks, rather than abrupt discontinuation. Cardiac hypersensitivity may occur 24-48 hours after propranolol is discontinued (peaks at 4-8 d).

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Propranolol ( Inderal, InnoPran XL)

 

Propranolol hydrochloride is a synthetic nonselective beta-adrenergic receptor blocking agent. Generic is available as 10-, 20-, 40-, 60-, and 80-mg tab and as 60-, 80-, 120-, and 180-mg extended-release tab. Inderal is available as 10-, 20-, 40-, 60-, and 80-mg tab for PO administration. InnoPran XL is available as 80- and 120-mg extended-release tab. No commercially available liquid formulation is available for use in children and must be formulated by a qualified pharmacist. Indicated for hypertension and a variety of other cardiac conditions (angina) and migraine headache prophylaxis.

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Interferons

Class Summary

Initially used as an antiviral agent in HIV-infected patients, interferon alfa-2a was found to induce regression of Kaposi sarcoma. This led to its use in treating other vascular lesions (eg, hemangiomas). Interferon alfa inhibits endothelial cell migration and proliferation and specific growth factors (eg, endothelial growth factor, fibroblast growth factor). Numerous studies have demonstrated the efficacy of interferon alfa-2a and interferon alfa-2b in treating infantile hemangiomas.[64, 65]

Because interferon alfa-2a works by a different mechanism, it can be used in lesions that are unresponsive to steroids.[66] In fact, unlike steroids, it does not require that administration occur during the proliferation phase to be effective. The onset of action is slower than that of corticosteroids, usually requiring several weeks; this makes it less attractive for use in acute life- or sight-threatening situations. Interferon alfa-2a should be used only if steroid, beta-blocker, and other potentially toxic therapies fail.

The most significant adverse event limiting its use in hemangiomas is potentially irreversible spastic diplegia; while most infants have displayed significant recovery of spasticity of lower extremities, it appeared permanent in other infants.[67, 68] A meta-analysis of interferon use in children revealed all cases of neurological dysfunction occurred when interferon was used prior to the patient’s first birthday.[69]

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Interferon alfa 2a (Roferon-A)

 

Protein product manufactured by recombinant DNA technology. Mechanism of antitumor activity is not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles. May be given topically, systemically, and intralesionally.

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Interferon alfa-2b (Intron A)

 

Protein product manufactured by recombinant DNA technology. Indications to treat adult hairy cell leukemia, malignant melanoma, condyloma acuminata, AIDS-related Kaposi sarcoma, and certain forms of chronic viral hepatitis. Has also used to treat children with these conditions and, most recently, infants with life-threatening hemangiomas.

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Biologic immune response modifiers

Class Summary

Only a few case reports and two small open-label uncontrolled trials suggest some minimal efficacy for the treatment of infantile hemangiomas.[70, 71, 72] This treatment should be considered experimental until placebo-controlled trials are performed and therapy is determined safe for infants. Imiquimod cream is the only medication in this new class. It purportedly works by stimulation of toll-like receptor 7 (TLR-7) and increases local interferon alpha and gamma, through which it may exert antiangiogenic effects. In a mouse model, imiquimod-treated vascular tumors showed decreased tumor cell proliferation, increased tumor apoptosis, and increased expression of tissue inhibitor of matrix metalloproteinase-1, with decreased activity of matrix metalloproteinase-9, both of which are observed in the natural involution of infantile hemangiomas.

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Imiquimod (Aldara cream)

 

Immune response modifier indicated for treatment of condyloma acuminata, actinic keratoses, and superficial basal cell carcinoma in adults. Not approved by FDA for use in children.

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Becaplermin 0.01% gel (Regranex Gel)

 

A few reports in the literature (Metz, 2004) suggest this is helpful for ulcerated infantile hemangiomas, especially those in the diaper area. Data limited and no placebo-controlled trial published to date. Seven infants with refractory ulcerated infantile hemangiomas experienced healing 3-21 d after initiating therapy.

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Contributor Information and Disclosures
Author

Richard J Antaya, MD  Director of Pediatric Dermatology, Associate Professor, Departments of Dermatology and Pediatrics, Yale University

Richard J Antaya, MD is a member of the following medical societies: American Academy of Dermatology, American Academy of Pediatrics, and Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Jean Paul Ortonne, MD  Chair, Department of Dermatology, Professor, Hospital L'Archet, Nice University, France

Jean Paul Ortonne, MD is a member of the following medical societies: American Academy of Dermatology and American Dermatological Association

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Van Perry, MD  Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

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Histopathology of a proliferating infantile hemangioma with plump endothelial cells in the dermis.
This proliferating superficial infantile hemangioma on the trunk required no therapy.
Exquisitely painful ulcerated mixed hemangioma (superficial and deep) of the left deltoid in a 6-month-old female infant. This lesion was treated successfully with pulsed dye laser.
This superficial and deep infantile hemangioma resulted in astigmatism of the left eye, requiring spectacles to correct the refractive error and to prevent amblyopia. Further growth of this hemangioma necessitated a course of oral prednisolone. The hemangioma shrunk rapidly, and the patient's astigmatism decreased such that the spectacles were unnecessary 1 month after beginning steroids.
Segmental infantile hemangioma in a female infant with PHACE syndrome involving the posterior neck and right forehead associated with an absent right vertebral artery and a laryngeal hemangioma.
Segmental infantile hemangioma with minimal or arrested growth of the bilateral buttocks and posterior thigh in this male infant with PELVIS syndrome (complicated by cutaneous ulceration, hypospadias, anal stenosis, intraspinal lipoma with tethered cord). The white material is a barrier diaper cream.
 
 
 
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