Understanding of childhood skin issues deepens

Key Points

"There are few times in our careers where we have a breakthrough that dramatically changes the way we practice medicine. And propranolol use for hemangiomas is one of those breakthroughs," says Sarah L. Chamlin, M.D., associate professor of pediatrics and dermatology, Children's Memorial Hospital, Chicago.

A group of physicians discovered propranolol's effectiveness for this indication when they treated a child with hemangioma for obstructive hypertrophic cardiomyopathy.

Propranolol's mechanism of action here remains unknown, she adds, but it could include vasoconstriction, cell apoptosis or decrease in vascular endothelial growth factor (VEGF) or beta fibroblast growth factor (bFGF).

Dr. Chamlin stresses that dermatologists must not minimize this treatment's side effects, which can include bradycardia, hypoglycemia, hypotension, heart block, hypothermia, bronchospasm and, most commonly in older infants, nightmares.

Conservative treatment

Since the initial publication, Dr. Chamlin says she and her colleagues have treated approximately 100 patients with propranolol.

"We are pretty conservative," she says, using baseline echocardiogram and 24-hour Holter monitors. "Most centers are only doing EKGs," she says, which may miss a brief arrhythmia. Moreover, "We start patients - as inpatients - at 1 mg/kg divided TID. Most centers around the country are doing outpatient treatment, and we are currently developing an outpatient protocol. But we believe that the first couple doses must be monitored after they're given."

Next, Dr. Chamlin and her colleagues repeat the Holter and increase dosage to 2 mg/kg/day outpatient, assuming the monitoring uncovers no irregularities. Other steps include making sure patients take medicines with food, and that parents wake children for regular feedings.

"In our experience," she adds, "it's the older children who are sleeping late" and missing meals who tend to develop hypoglycemia while on treatment. "There have been a handful of 911 calls for children on propranolol who were lethargic or unresponsive due to hypoglycemia."

Furthermore, "We are cautious about using propranolol in children with PHACES syndrome because of their arterial abnormalities of the neck and central nervous system (CNS)," Dr. Chamlin says.

In the context of decreased CNS blood flow, it is unknown whether decreasing heart rate may increase the risks for an ischemic stroke, she says.

Accordingly, Dr. Chamlin says she treats such children only if evaluation shows that they have adequate CNS arteries. In such cases, she has used CNS perfusion scanning in an ICU for the first day of treatment, and also treats with low-dose aspirin.

Overall, she says, "I'm using propranolol much more freely for disfiguring and function-threatening hemangiomas. For any disfiguring hemangiomas on the face, I've been using it with help from a pediatric cardiologist."

She adds that the ability to treat beard-distribution hemangiomas with subglottic involvement represents "a huge breakthrough. In past experience, a minority of these patients got tracheostomy tubes. But with our experience during the past year, we haven't had to do this for any of our patients with subglottic involvement."

Nevertheless, Dr. Chamlin says, "I have not given up on systemic steroids. I still use them in some cases."

Systemic corticosteroids make it easier to start patients on treatment the day of their appointment, Dr. Chamlin says, whereas it can take a week to two weeks to begin propranolol treatment after baseline testing.