Infantile haemangiomas that failed treatment with propranolol: clinical and histopathological features.

AIM: To describe the clinical and histopathological characteristics of infantile haemangiomas that failed treatment with oral propranolol . DESIGN: This study is a case series from the vascular birthmarks clinic at Royal Children's Hospital, Melbourne. PATIENTS: The patients for this study were infants who commenced treatment with oral propranolol before 6 months of age and who were treated for at least 4 months without a satisfactory result. For histology and immunohistochemistry, tissue from the four non-responding patients who subsequently underwent surgical excision was matched with four historical controls. OUTCOME MEASURES: Based on medical record review and photographic assessments, infants were defined as having failed treatment with oral propranolol if the infantile haemangioma either continued to grow or showed 20% improvement or less. Tissue sections were examined for tissue structure, mast cells, sympathetic innervations and beta-2 adrenergic receptor expression, and the number of mast cells and beta-2 adrenergic positive cells. RESULTS: From a group of 135 infants who met the inclusion criteria, 14 infants failed propranolol treatment. Eleven of these infants had focal facial haemangiomas. No difference was seen in tissue morphology, tissue innervations, beta-2 adrenergic receptor expression, cell number or mast cell distribution, and number between non-responding and control haemangiomas. CONCLUSION: We report a treatment failure rate of 10%, which is higher than previously reported. Focal facial lesions failed to respond twice as frequently as other types of haemangioma. No histopathological reason was identified to indicate why some haemangiomas failed to respond.

Use of propranolol for treatment of infantile haemangiomas in an outpatient setting.

INTRODUCTION: Propranolol has recently emerged as an effective drug treatment for infantile haemangiomas. The side effect profile of the drug and the safety of administering propranolol in outpatient settings in this age group remain uncertain. We report our experience with 200 infants and children prescribed propranolol to treat infantile haemangiomas, including 37 patients considered to have a poor response to treatment. METHOD: Patients were prescribed propranolol (1 mg/kg/dose bd) as outpatients at the Vascular Anomalies Service at the Royal Children's Hospital, Melbourne. RESULTS: The median age at commencement was 4 months (range 5 days-7 years). Twenty patients were older than 12 months at commencement. The median duration of treatment was 8 months. About 80% of treated haemangiomas were on the face. Approximately 50% of patients were considered to have an excellent response, 30% to have a good response and 20% to have a poor response. All segmental facial haemangiomas responded well. In contrast, 25% of focal facial haemangiomas responded poorly. Sleep disturbance was the most common side effect. Gross motor abnormalities including delayed walking were observed in 13 patients. CONCLUSION: Propranolol appears to be an effective treatment for infantile haemangiomas, particularly large segmental facial lesions. A poor response was seen in 20% of patients. Treatment has been provided in an outpatient setting without major complications and with excellent parental compliance. The side effect profile appears to be favourable, but further follow-up is required to identify unexpected long-term side effects.