Podium Talk: Optimizing Treatment for Infantile Hemangiomas: A Case Report on the Use of Timolol and Timing of Oral Propranolol Initiation
Location
Moultrie, GA
Start Date
7-5-2025 2:15 PM
End Date
7-5-2025 3:15 PM
Description
Introduction: Infantile hemangiomas (IHs), are the most common vascular tumors in infancy and are thought to be due to an abnormal response to pluripotent stem cells. The critical proliferation period is during the first three to five months of life, with rapid growth occurring in the first two months. Many infantile hemangiomas spontaneously involute, though some have complications requiring further treatment. For complicated hemangiomas, the initiation of therapy is recommended before eight weeks of age to reduce the need for more invasive management, such as surgical correction. The most current protocol for treating infantile hemangiomas emphasizes early evaluation and intervention to prevent potential complications. Management is based on the hemangioma's size, location, growth characteristics, and the presence of any associated symptoms.
Case Presentation: In this case, an infant presented at approximately week two of life to the emergency department with a lesion on her gluteal region that appeared to be fungal in nature. Because of the rapid enlargement of the lesion over the following days, she was brought back into the office to be re-evaluated. At this point, a dermatological referral was placed due to concern for a hemangioma. After discussion, the patient was initially treated with 0.5% of topical timolol twice daily due to not yet being five weeks old, but the now ulcerating hemangioma failed to respond. A decision was then made to initiate oral propranolol following current protocol.
Discussion: Geographic and healthcare access barriers can impact the timely management of infantile hemangiomas (IHs). In regions such as South Georgia, where access to pediatric dermatology specialists may be limited, diagnosis and treatment initiation delays can contribute to suboptimal outcomes. In this case, due to a lack of resources and inability of local pharmacies to procure an oral prescription of propranolol, a week-long delay in care resulted. Furthermore, current guidelines regarding oral propranolol treatment for infants under five weeks old are vague, which causes delays in initiating the appropriate therapy, emphasizing the importance of improved clinical protocols and anticipatory guidance.
An essential question in this case is whether the high risk of ulceration in segmental IHs justifies the initiation of propranolol earlier than five-weeks of age. Current clinical practice guidelines recommend propranolol as a first-line treatment for high-risk IHs. However, there is still ongoing discussion about the safest timing for initiating therapy in infants. Other variables, including patient weight and age at delivery, should also be considered when deciding on treatment delay. Items to consider would be that this patient was born at 40 weeks and 4 days with a weight at diagnosis of 3.83 kg. Given this patient's ultimate need for propranolol despite an initial trial of topical timolol therapy, an earlier start to systemic treatment, when considering the patient's weight and gestational age, may have prevented ulceration and associated complications.
Embargo Period
5-20-2025
Podium Talk: Optimizing Treatment for Infantile Hemangiomas: A Case Report on the Use of Timolol and Timing of Oral Propranolol Initiation
Moultrie, GA
Introduction: Infantile hemangiomas (IHs), are the most common vascular tumors in infancy and are thought to be due to an abnormal response to pluripotent stem cells. The critical proliferation period is during the first three to five months of life, with rapid growth occurring in the first two months. Many infantile hemangiomas spontaneously involute, though some have complications requiring further treatment. For complicated hemangiomas, the initiation of therapy is recommended before eight weeks of age to reduce the need for more invasive management, such as surgical correction. The most current protocol for treating infantile hemangiomas emphasizes early evaluation and intervention to prevent potential complications. Management is based on the hemangioma's size, location, growth characteristics, and the presence of any associated symptoms.
Case Presentation: In this case, an infant presented at approximately week two of life to the emergency department with a lesion on her gluteal region that appeared to be fungal in nature. Because of the rapid enlargement of the lesion over the following days, she was brought back into the office to be re-evaluated. At this point, a dermatological referral was placed due to concern for a hemangioma. After discussion, the patient was initially treated with 0.5% of topical timolol twice daily due to not yet being five weeks old, but the now ulcerating hemangioma failed to respond. A decision was then made to initiate oral propranolol following current protocol.
Discussion: Geographic and healthcare access barriers can impact the timely management of infantile hemangiomas (IHs). In regions such as South Georgia, where access to pediatric dermatology specialists may be limited, diagnosis and treatment initiation delays can contribute to suboptimal outcomes. In this case, due to a lack of resources and inability of local pharmacies to procure an oral prescription of propranolol, a week-long delay in care resulted. Furthermore, current guidelines regarding oral propranolol treatment for infants under five weeks old are vague, which causes delays in initiating the appropriate therapy, emphasizing the importance of improved clinical protocols and anticipatory guidance.
An essential question in this case is whether the high risk of ulceration in segmental IHs justifies the initiation of propranolol earlier than five-weeks of age. Current clinical practice guidelines recommend propranolol as a first-line treatment for high-risk IHs. However, there is still ongoing discussion about the safest timing for initiating therapy in infants. Other variables, including patient weight and age at delivery, should also be considered when deciding on treatment delay. Items to consider would be that this patient was born at 40 weeks and 4 days with a weight at diagnosis of 3.83 kg. Given this patient's ultimate need for propranolol despite an initial trial of topical timolol therapy, an earlier start to systemic treatment, when considering the patient's weight and gestational age, may have prevented ulceration and associated complications.