Infantile haemangioma

Infantile haemangioma describes a benign (non-cancerous) condition affecting cutaneous blood vessels. It is also known as proliferative haemangioma because it is due to proliferating endothelial cells; these are the cells that line blood vessels
Infantile haemangiomas are proliferative lesions that usually develop shortly after birth. They are distinct from vascular malformations, which are usually present at birth and are less common
Over 80% of infantile haemangiomas occur on the head and neck area. They grow to 80% of maximum size in the first three months and most stop growing at about 5 months. However, they may keep growing for up to 18 month.
After that, they undergo regression or involution. This can take as long as 3-10 years. Nearly all flat infantile haemangiomas eventually involute and disappear without treatment. However, regression of bulky haemangiomas tends to be incomplete, and they may leave an irregular atrophic (thin) scar  in at least 50% 
of cases

Propranolol for infantile hemangioma

Propranolol is a medicine from the class of beta-blockers. It has been used in the treatment of high blood pressure and other medical conditions for decades. Since 2008 it has also been used off-license for the treatment of complicated infantile haemangiomas. The majority of infantile haemangiomas are not at risk of complication and do not require treatment.

?How does propranolol work in infantile haemangiomas

Propranolol is thought to inhibit the growth of blood vessels and constrict existing blood vessels within the haemangioma. It acts on beta adrenergic receptors to decrease the release of blood vessel growth-signalling molecules (vascular endothelial growth factor and basic fibroblast growth factor) and by triggering programmed cell death

?When should propranolol be considered

In many cases, haemangiomas are small and hidden; once they have reached their full size, they can be expected to slowly shrink over the next few years. These do not require treatment. However, propranolol should be considered when there is a risk of a complication. Indications for treatment include infantile haemangiomas that are growing in high risk sites where they may interfere with normal function such as breathing, feeding, vision and hearing.
  • Within the airway
  • Around the eye
  • Around the mouth or on the lips
  • Within the ear canal
  • On the tip of the nose
  • Large lesions on the face
  • Napkin area
  • Skin creases
  • PHACES syndrome (large segmental facial haemangioma)
  • PELVIS syndrome (large segmental lumbosacral haemangioma)
  • Multiple haemangiomas including visceral (internal) lesions.

How effective is propranolol at treating infantile haemangiomas

Propranolol is most effective when started during the growth phase of the haemangioma, in infants up to 6 months of age; they may begin to respond within 24 to 48 hours. The haemangioma softens (decrease in volume) and darkens in colour. The optimal duration of treatment is yet to be established, though most reports are of use for 3-12 months. Rebound growth may occur on cessation and gradual weaning may be required.
Propranolol may also be effective if it is started after the growth phase, even over the age of 12 months. It may speed up the rate at which the haemangioma decreases in size and eventually disappears. 

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