Haemangiomas can be treated with propranolol, a medicine traditionally used to treat high blood pressure.
Propranolol has been used in France and the United States with success and is now being used at Great Ormond Street Hospital (GOSH). Not all haemangiomas are suitable for this form of treatment.
What is a haemangioma?
A haemangioma is a collection of small blood vessels that occur under the skin. They are sometimes called ‘strawberry marks’ because the surface of a haemangioma looks a bit like a strawberry.
Haemangiomas can be superficial or deep in the skin. Some haemangiomas are a combination of the two, seen as a raised red area on the surface of the skin, or as a bluish swelling of abnormal blood vessels deeper in the skin.
Haemangiomas are not usually obvious at birth but become apparent within a few days or weeks. They grow rapidly in the first three months, increasing in size and sometimes in redness.
It is unusual for haemangiomas to grow after six to 10 months of age, when most haemangiomas tend to have a ‘rest period’ and then begin to shrink.
How are haemangiomas usually treated?
The traditional treatment for complicated haemangiomas, for example near the eye, on the lips or nappy area, has been steroids.
Steroids are usually prescribed as dissolvable tablets and need to be given exactly according to instructions. When the haemangioma is stable (usually around the age of five to six months), the dose is gradually reduced and stopped. It is dangerous to stop steroids suddenly.
Propranolol is now being used as an alternative to steroid treatment, particularly if a patient cannot take steroids, for instance, soon after some immunisations, or if steroids have not worked very well previously.
Propranolol is not suitable for everyone, and children who start propranolol treatment have to be monitored closely before, during and after treatment.
What is propranolol?
Propranolol is a beta-blocker. Some nerves release a chemical called noradrenaline when they are stimulated which in turn stimulates 'beta adrenergic receptors'. These can cause a variety of effects.
For instance, if the beta adrenergic receptors in the heart are stimulated, the heart pumps harder and faster than before, so more blood is pumped around the body. Beta-blocker medicines block the beta adrenergic receptors and stop them being stimulated.
How does propranolol help with haemangiomas?
By blocking the beta adrenergic receptors, propranolol can make blood vessels tighten, reducing the amount of blood flowing through them. This is particularly helpful in haemangiomas, as it reduces the blood flow through them, reducing the colour and making them softer.
The cells that cause the growth of the haemangioma are also affected by propranolol so that the haemangioma starts to reduce in size. More research is needed to confirm that this is how propranolol works, but the beneficial effects are usually seen very quickly.
Are there side effects with propranolol treatment?
Propranolol is associated with the following side effects, which happen very rarely. However, you should report any of the following to your doctor as the dose of propranolol may need to be altered or on very rare occasions, stopped.
- bradycardia (slow heart rate)
- hypotension (low blood pressure)
- bronchspasm (temporary narrowing of the airway, leading to wheezing and coughing)
- peripheral vasoconstriction (reduced blood flow to the extremities, such as fingers and toes, making them feel cold and turn a blue colour)
- weakness and fatigue, showing as floppiness and disinterest in surroundings
- sleep disturbance
- hypoglycaemia (low blood sugar)
If you have any concerns about these side effects, please discuss them with your doctor, nurse or pharmacist.
What tests are needed before starting propranolol treatment?
Before your child starts propranolol treatment, we need to check that they can safely take the medicine.
Your child will have a range of tests, including blood and urine tests, an electrocardiogram (ECG), echocardiogram (Echo) and clinical photography.
If your child has more than five haemangiomas visible on the skin, we will also carry out an abdominal ultrasound scan. This will show any haemangiomas deeper in the body.
What happens when my child starts treatment?
For the first two hours, your child will be closely monitored. Every half hour your child’s pulse and blood pressure will be measured accurately, to ensure that they have not dropped too low. This close monitoring allows the doctors to be absolutely sure your child can tolerate the prescribed dose.
The procedure is repeated after one week when the dose is increased. If your child was born prematurely or at low birthweight, this monitoring may carry on for four hours or longer.
Your child's community nurses should check your child's heart rate and blood pressure three to four days after starting treatment and then every week while your child is taking propranolol.
We will give you a copy of our protocol (treatment guidelines) to give to your GP, outlining this is more detail.
Please remember to bring all your child's results to outpatient appointments.
What dose should my child take?
Your child’s dose is worked out depending on their weight. This will mean that the dose may change over time as your child grows.
At GOSH, we supply propranolol as a 5mg/5ml liquid - that is, 5ml of liquid contains 5mg of the active ingredient.
The British Society for Paediatric Dermatology has highlighted that there are three strength of propranolol oral solution: 5mg/5ml, 10mg/ml and 50mg/ml. Following incidents where propanolol 50mg/5ml has been dispensed by pharmacists instead of 5mg/5ml, parents are asked to check the dose with your pharmacist before giving it to your child. Ideally any other strength should be avoided to minimize any risk of the wrong dose being given to your child.
If you have any queries about propranolol, please talk to your nurse, doctor or pharmacist.
How long does treatment last?
In our experience, treatment to 12 to 16 months of age with propranolol is usually sufficient to reduce the haemangioma so that it does not cause any troublesome side effects.
Propranolol should not be stopped suddenly so your child will gradually be weaned off the medicine, reducing the dose over a period of weeks.
What happens next?
Most haemangiomas will have disappeared completely by the age of five to seven years. Large haemangiomas may continue to get smaller until your child is about eight to 10 years old.
Depending on the size and location of the haemangioma, there may be little sign it ever existed.
Last reviewed by Great Ormond Street Hospital: September 2012
Ref: 2012F0835 September 2012
Compiled by the Birthmark Unit in collaboration with the Child and Family Information Group.
Please read this information in conjunction with any patient information leaflet provided by the manufacturer. However, please note that this information explains about the use of medicines in children and young people so may differ from the manufacturer’s information.
Each person reacts differently to medicines so your child will not necessarily suffer every side effect mentioned. This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.
