Treating small infantile haemangiomas with topical timolol

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. Applying timolol to the skin surface is one option for treating very small haemangiomas. 

Haemangiomas near the eye, on the lips or in the nappy area, for example, can be treated with beta-blocker medications given orally (by mouth) or applied topically (as a gel applied to the surface of the haemangioma). Topical application is only used for small haemangiomas.

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.

In most cases, haemangiomas require no special treatment. However, for complicated haemangiomas, for example, those near the eye, on the lips or in the nappy area, beta-blocker medications have become the first line treatment over the last four years.

What is timolol maleate and how does it help with haemangiomas?

Timolol maleate is a beta-blocker medication, which means it blocks beta adrenergic receptors. By blocking the beta adrenergic receptors, timolol 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 haemangioma are also affected by timolol so that the haemangioma starts to reduce in size.

More research is needed to confirm exactly how timolol works, but the beneficial effects are usually seen very quickly.

Timolol comes in a variety of formats, but the one currently used at Great Ormond Street Hospital is a gel-forming solution called Timoptol®-LA 0.5% originally used for treating raised eye pressure. This gel-forming solution is used as it is easier to apply to the skin.

Are there any side effects with topical timolol treatment?

Topical administration of timolol is safe and side effects are extremely rare. However, you should report any of the following to your doctor as the dose of timolol may need to be altered or on very rare occasions, stopped. We will explain the side effects to you at the first consultation.

Very rare side effects:

  • 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

  • hypoglycemia (low blood sugar)

If you have any concerns about these side effects, please discuss them with your doctor, nurse or pharmacist.

Are there any tests needed before starting timolol treatment?

If your child has more then five haemangiomas visible on the skin, we may carry out an abdominal ultrasound scan to look for haemangiomas deeper in the body.

Also, before starting treatment and at each visit after starting treatment, your child will have clinical photographs taken. If your baby was born prematurely, please let us know at your first appointment as this may affect the dose of timolol prescribed.

What dose should my child have?

The dose of topical timolol is one drop three times a day. You should apply the drop directly to the haemangioma and carefully spread it with your finger to cover the surface of haemangioma. Please wash your hands with soap and water before and after putting timolol on your child’s skin.

How long does the treatment last?

We expect treatment to continue for up to six months or one year. Your child will be reviewed each month after starting the treatment so the doctors can decide whether the topical treatment is working.

If topical treatment with beta-blockers is not sufficient to stop the haemangioma from growing, then an oral beta-blocker medication may be prescribed in selected cases.

What happens next?

Seventy per cent of haemangiomas will have disappeared completely by the age of five to seven years.

Depending on the size and location of the haemangioma, there may be little sign it ever existed.

Compiled by: 
The Birthmark Unit in collaboration with the Child and Family Information Group.
Last review date: 
June 2014
Ref: 
2014F1431

Disclaimer

Please read this information sheet from GOSH alongside the patient information leaflet (PIL) provided by the manufacturer. If you do not have a copy of the manufacturer’s patient information leaflet please talk to your pharmacist. A few products do not have a marketing authorisation (licence) as a medicine and therefore there is no PIL.

For children in particular, there may be conflicts of information between the manufacturer’s patient information leaflet (PIL) and guidance provided by GOSH and other healthcare providers. For example, some manufacturers may recommend, in the patient information leaflet, that a medicine is not given to children aged under 12 years. In most cases, this is because the manufacturer will recruit adults to clinical trials in the first instance and therefore the initial marketing authorisation (licence) only covers adults and older children.  

For new medicines, the manufacturer then has to recruit children and newborns into trials (unless the medicine is not going to be used in children and newborns) and subsequently amend the PIL with the approved information. Older medicines may have been used effectively for many years in children without problems but the manufacturer has not been required to collect data and amend the licence. This does not mean that it is unsafe for children and young people to be prescribed such a medicine ‘off-licence/off-label’. However, if you are concerned about any conflicts of information, please discuss with your doctor, nurse or pharmacist.