We read with interest the article “Management of Complicated Facial Hemangiomas with Beta-Blocker (Propranolol) Therapy.”1 We have recently treated 31 consecutive patients with rapidly proliferating hemangioma using propranolol as a first-line treatment.2 We performed similar pretreatment cardiovascular workup and commenced administration of propranolol at 3 mg/kg/day. A rapid halt in hemangioma proliferation was seen in 100 percent of patients, and significant regression was seen in 87 percent of patients. This treatment was well tolerated and had few side effects.
We used a higher dosage of propranolol, as experimental studies have shown that the effect of propranolol is dose-dependent. Recent in vitro studies had suggested that propranolol efficacy is dose-dependent in reducing proliferation of tumor stem cells3 and placental endothelial cells.4
We do not use a weaning regimen for propranolol as in this study. All patients are followed up every 2 weeks, with monitoring of any adverse side effects, blood pressure, and pulse rate.
We also believe that to avoid rebound growth, optimum treatment should cover the majority if not all the proliferative phase (i.e., until the child is at least 7 to 8 months old). We did not see any improvement in patients in whom treatment was started beyond the proliferative phase, in contrast to some of the other studies.
There is as yet no consensus on the ideal treatment regimen with propranolol, and we agree with the authors that further comparative studies are needed to determine the most effective treatment dosage and optimum treatment duration. It is also important to determine the exact mechanism of action of propranolol in future scientific studies, to exploit its potential further.
Anuj Mishra, M.R.C.S.
William Holmes, M.R.C.S.
Catherine Gorst, R.G.N., R.S.C.N.
Sehwang Liew, F.R.C.S.Plast.
Vascular Birthmark Center
Alder Hey Children's Hospital
Liverpool, United Kingdom
1. Arneja JS, Pappas PN, Shwayder T, et al. Management of complicated facial hemangiomas with beta-blocker (propranolol) therapy. Plast Reconstr Surg
2. Holmes WJ, Mishra A, Gorst C, Liew SH. Propranolol as first-line treatment for rapidly proliferating infantile haemangiomas. J Plast Reconstr Aesthet Surg
. (in press).
3. O T, Waner M, Xu D, et al. Vandetanib and propranolol inhibit infantile hemangioma (IH) and NICH cell growth in vitro. Presented at: 18th International Workshop on Vascular Anomalies; April 21–24, 2010; Brussels, Belgium.
4. Yang Q, Kumar S, Salalto V, Szabo S, North PE. Propranolol inhibits proliferation and tube formation by purified placental capillary endothelial cells, an in vitro model for infantile hemangioma (IH), and induces their apoptosis. Presented at: 18th International Workshop on Vascular Anomalies; April 21–24, 2010; Brussels, Belgium.
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