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Role of Propranolol in the Management of Periocular Hemangiomas

Mishra, Anuj M.R.C.S.; Holmes, William J. M. M.R.C.S.; Gorst, Catherine R.G.N., R.S.C.N.; Liew, Sehwang H. F.R.C.S.

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Plastic and Reconstructive Surgery: August 2010 - Volume 126 - Issue 2 - p 671
doi: 10.1097/PRS.0b013e3181de1a32
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We read with great interest the article entitled “Resection of Amblyogenic Periocular Hemangiomas: Indications and Outcomes,” particularly the section on their management.1 We are all too aware of the difficulties, such as timing of intervention and the inadequacy of conventional therapies.

We agree with the authors regarding the role of early resection of a well-localized periocular hemangioma to prevent potentially irreversible amblyopia caused by either corneal deformation or blepharoptosis and the partial response with oral or intralesional steroids. Intralesional or oral corticosteroid administration was attempted in almost half of the authors' series.

Recently, a number of cases have been reported regarding the efficacy of propranolol in the treatment of hemangioma.2,3 As part of a larger study, we have used propranolol in a total of 27 patients, including seven periocular hemangiomas as a first-line management. We have noticed a considerable improvement in both color and thickness within the first 24 hours and a halt in lesion progression in 100 percent within 48 hours. Furthermore, 50 percent of the lesions have shown significant reduction within 4 weeks of treatment of propranolol alone. So far, there have been no side effects to treatment, in contrast to other reports.4 Consequently, we now offer propranolol as a first-line treatment for all hemangiomas with functional deficit and/or disfigurement according to a specific treatment protocol, published earlier,5 that involves pretreatment cardiac workup and a titrated dose of propranolol to 1 mg/kg three times daily. In our series, all periocular hemangiomas are managed in a multidisciplinary setup, with propranolol as the first-line therapy.

Although we agree with all the points raised in your article, we would like to suggest that β-blocking agents have an important role in the management of all hemangiomas, including periocular hemangiomas.

Anuj Mishra, M.R.C.S.

William J. M. Holmes, M.R.C.S.

Catherine Gorst, R.G.N., R.S.C.N.

Sehwang H. Liew, F.R.C.S.

Department of Plastic and Reconstructive Surgery

Alder Hey Children's Hospital

Liverpool, United Kingdom


1. Arneja JS, Mulliken JB. Resection of amblyogenic periocular hemangiomas: Indications and outcomes. Plast Reconstr Surg. 2010;125:274–281.
2. Leaute-Labreze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taib A. Propranolol for severe hemangiomas of infancy. N Engl J Med. 2008;358:2649–2651.
3. Buckmiller L, Dyamenahalli U, Richter GT. Propranolol for airway hemangioma: Case report of novel treatment. Laryngoscope 2009;119:2051–2054.
4. Lawley LP, Siegfried E, Todd JL. Propranolol treatment for hemangioma of infancy: Risks and recommendations. Pediatr Dermatol. 2009;26:610–614.
5. Holmes WJ, Mishra A, Gorst C, Liew SH. Propranolol as first-line treatment for infantile hemangiomas. Plast Reconstr Surg. 2010;125:420–421.

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