LJM 1993-2820 1819-6357 Libyan Journal of Medicine, Vol. 6, No. 00, January 2011, pp. 1–3 sici xxx PUBMED Abbreviation Victor Grech

*Victor Grech, Consultant Pediatrician (Cardiology), Paediatric Department, Mater Dei Hospital, Tal-Qroqq Malta 00356 25458000

Carmen Scerri Consultant Pediatrician (Cardiology), Paediatric Department Mater Dei Hospital

Tal-Qroqq Malta

Midwifery Coordinator St. James Hospital

Sliema Malta

Libyan Journal of Medicine CASE REPORT Propranolol for infantile haemangiomas Capillary haemangiomas are benign lesions that may occur anywhere on the skin, may grow rapidly in the first two years of life and may impair vital organs. Propranolol has been recently discovered to shrink these lesions effectively. We report the first such patient treated in Malta with this drug. haemangioma propranolol Our patient was a 6-month-old female Libyan infant who was delivered uneventfully in Malta at St. James Hospital in Sliema. Shortly after the baby returned to Libya, the parents noted a capillary haemangioma on the lateral aspect of the left arm. This lesion rapidly proliferated and ulcerated with a serous, non-infected discharge, probably as a result of frequent trauma as would be expected in an infant of this age with a lesion at this location. The lesion was tense, reddish purple all over, measured 53×44 mm, and was elevated by 20 mm above the skin surface (Fig. 1).

Initial appearance of haemangioma prior to commencing oral propranolol.

Due to the ulceration, discharged, and possibility of infection, propranolol was commenced at a dose of 1 mg/kg/dose thrice daily. Blood pressure remained stable and propranolol was increased to 2 mg/kg/dose thrice daily in the second week of treatment. The lesion exhibited rapid involution with shrinkage and reappearance of patches of normal skin. The child developed varicella and this did not have any effect on the lesion or treatment whatsoever. Propranolol was stopped after 6 weeks (Fig. 2) with the lesion measuring 40×20 mm and elevated 10 mm above the skin.

Appearance of haemangioma after 6 weeks of treatment with oral propranolol.

The practice of any aspect of science – including that of medicine – requires the independent replication of new ideas and results and, if these are confirmed, a paradigm shift occurs with the rejection of conventional theory and acceptance of the new standard. Breakthroughs commonly occur serendipitously in all branches of science including medicine. Serendipity is the propensity for making fortuitous discoveries while looking for something unrelated. An important aspect is the ‘sagacity’ of being able to link together apparently unrelated facts to come to a valuable conclusion. The list of such discoveries is endless including, for example, the accidental discovery of penicillin, the useful side effect of minoxidil for the promotion of hair growth in a drug initially developed for the treatment of hypertension, and the useful side effect of penile erection with sildenafil, a drug initially developed to treat coronary artery disease 6. The mechanisms of haemangioma proliferation are uncertain, and it is believed that such growth is regulated through mediators such as basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) 7. Propranolol is a non-selective beta-blocker developed in the late 1950s and possible actions for promoting haemangioma involution, while uncertain, may include an immediate vasoconstriction within the lesion resulting in rapid colour change and palpable softening, decreased expression of VEGF and bFGF genes, and triggering of apoptosis of the endothelial cells contained within the lesion 7. Propranolol is an effective and well-tolerated treatment in the management of selected cases of severe haemangiomas in infancy. Side effects include bradycardia, hypotension, and hypoglycaemia in very young infants and neonates, but these effects are typically mild and short lived. Indeed, after more than 40 years of clinical use in infants, there is no documented case of death or serious cardiovascular disease as a direct result of exposure to a beta-blocker in the literature 8. In our patient, treatment was stopped after 6 weeks as the lesion had involuted significantly with no residual ulceration, and the natural history of such lesions is spontaneous resolution. We hope that this publication will raise awareness among clinicians in Libya and in Malta with regard to this new treatment for significant haemangiomas by this old and inexpensive drug. The authors have not received any funding or benefits from industry or elsewhere to conduct this study. Drolet BA Esterly NB Frieden IJ. Hemangiomas in children N Engl J Med. 1999 341 173 81 Haggstrom AN Drolet BA Baselga E Chamlin SL Garzon MC Horii KA Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics J Pediatr. 2007 150 291 4 Bruckner AL Frieden IJ. Infantile hemangiomas J Am Acad Dermatol. 2006 55 671 82 Kilcline C Frieden IJ. Infantile hemangiomas: how common are they? A systematic review of the medical literature Pediatr Dermatol. 2008 25 168 73 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 51 Pepys MB. Science and serendipity Clin Med. 2007 7 562 78 Storch CH Hoeger PH. Propranolol for infantile haemangiomas – insights into the molecular mechanisms of action Br J Dermatol. 2010 163 269 74 Love JN Sikka N. Are 1–2 tablets dangerous? Beta-blocker exposure in toddlers J Emerg Med. 2004 26 309 314