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Reply: Management of Complicated Facial Hemangiomas with Beta-Blocker (Propranolol) Therapy

Arneja, Jugpal S. M.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1743
doi: 10.1097/PRS.0b013e31820a65b9
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University of British Columbia; British Columbia Children's Hospital; Division of Plastic Surgery; A237 Shaughnessy Building, Box 150; 4480 Oak Street; Vancouver, British Columbia V6H 3V4, Canada; jugpal.arneja@ubc.ca

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Sir:

I thank the authors for their kind and thoughtful comments regarding our recently published article.1 My colleagues and I applaud their recent publication2 and others3,4 that have illustrated remarkable results with the use of beta-blockers for infantile hemangioma with limited deleterious sequelae. In contrast, there are reports of adverse events that cannot be ignored,5–7 because unrecognized hypoglycemia, bronchospasm, hypotension, or bradycardia could produce a disastrous outcome. Furthermore, to date, propranolol has not been shown to be a panacea, and for a complicated hemangioma producing functional problems, aggressive intervention may be requisite.8

Advances in a particular field of medicine ideally occur in a translational research model in which hypothesis-driven bench research can then be studied in well-structured human trials. However, on occasion, medical advances are serendipitous in nature and controlled study occurs in reverse fashion, which is, of course, the status of beta-blockers for the treatment of infantile hemangioma. Our goal as consultants is to provide best practices of patient care through careful scrutiny of evidence surrounding new innovation; a departure from this tenet could lead to breach of the dictum primum non nocere. It is well acknowledged that advances are initially met with an excitement period, followed by an evaluative and reflective period, with the ultimate arrival at a steady state of accepted clinical utility. It can be argued that the “jury is still deliberating” on the true place of beta-blockers in the treatment algorithm for infantile hemangioma because of absence of a published controlled prospective trial; in time, the collective body of literature on this subject will define treatment indications, therapeutic regimen, clinical efficacy, complication profile, and mechanism of action.

Finally, I would be remiss if I did not congratulate their institution's vascular birthmark center, because through research, teaching, and multidisciplinary clinical care of patients with vascular anomalies, a future generation of “next practices” will surely be cultivated.

Jugpal S. Arneja, M.D.

University of British Columbia

British Columbia Children's Hospital

Division of Plastic Surgery

A237 Shaughnessy Building, Box 150

4480 Oak Street

Vancouver, British Columbia V6H 3V4, Canada

jugpal.arneja@ubc.ca

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REFERENCES

1. Arneja JS, Pappas PN, Shwayder TA, et al. Management of complicated facial hemangiomas with beta-blocker (propranolol) therapy. Plast Reconstr Surg. 2010;126:889–895.
2. Holmes WJ, Mishra A, Gorst C, Liew SH. Propranolol as first-line treatment for rapidly proliferating infantile haemangiomas. J Plast Reconstr Aesthet Surg. Epublished ahead of print August 4, 2010.
3. Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med. 2008;358:2649–2651.
4. Sans V, de la Roque ED, Berge J, et al. Propranolol for severe infantile hemangiomas: Follow-up report. Pediatrics 2009;124:e423–e431.
5. Holland KE, Frieden IJ, Frommelt PC, Mancini AJ, Wyatt D, Drolet BA. Hypoglycemia in children taking propranolol for the treatment of infantile hemangioma. Arch Dermatol. 2010;146:775–778.
6. Lawley LP, Siegfried E, Todd JL. Propranolol treatment for hemangioma of infancy: Risks and recommendations. Pediatr Dermatol. 2009;26:610–614.
7. Breur JM, de Graaf M, Breugem CC, Pasmans SG. Hypoglycemia as a result of propranolol during treatment of infantile hemangioma: A case report. Pediatr Dermatol. Epublished ahead of print August 4, 2010.
8. Arneja JS, Mulliken JB. Resection of amblyogenic periocular hemangiomas: Indications and outcomes. Plast Reconstr Surg. 2010;125:274–281.

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