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The Impact of Combined Steroid-propranolol Therapy on the Involution of Infantile Hemangioma

Received: 17 September 2020     Accepted: 7 October 2020     Published: 17 October 2020
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Abstract

Infantile hemangioma (IH) is the most common benign vascular neoplasm of infancy, occurring in 1.0–2.5% of white infants, especially girls. Steroids and propranolol are the most widely used drugs as a primary treatment for IH. Although their mechanism of action is not well understood, their beneficial effect is documented. Our purpose was to compare the clinical efficacy of propranolol alone and propranolol combined with steroids on the outcome of IH. A total of 450 children (median age: 9 months; range: 7 days to 3 years) were included in this randomized controlled study, being treated with combined steroid and propranolol (Group A: 230 children) compared to those treated with propranolol plus placebo (Group B: 220 children). The steroid was given as a loading dose of 2–3 mg/kg/day and then gradually tapered over 6 months, whereas propranolol was given as an incremental dose starting at 0.16 mg/kg/day and reaching a maximum of 2 mg/kg/day maintained for 18 months (duration of therapy). Frequent monitoring of the blood sugar level was mandatory in the first 2 months: electro- and echocardiograms were recorded initially but not repeated. A more rapid involution rate, recognized by color fading and flattening of the lesions, was noted in Group A compared to Group B, with the peak response reached after 10 months of therapy followed by a slower but steady rate of further improvement. No major adverse effects were observed in Group A with regard to hypoglycemia or hypotension. On the other hand, ten cases of vomiting and diarrhea, one case of fungal infection and twelve cases of somnolence and fatigue were observed in Group B. Steroid induction seems to cover the gap at initiation of therapy where propranolol cannot be given as a full dose, especially in neonates. Steroid combination minimizes the adverse effects of propranolol, namely, hypoglycemia, hypotension and bradycardia. Children treated with a combined regimen showed more effective clearing of lesions, were less likely to require surgery for residual lesions and had minimal adverse effects compared to the single-drug group. In both groups there was a faster clearing rate for the head and neck lesions than elsewhere in the body, which can be explained by the higher blood flow to this region, magnifying the level of medication to these lesions and achieving a better response.

Published in American Journal of Pediatrics (Volume 6, Issue 4)
DOI 10.11648/j.ajp.20200604.13
Page(s) 397-407
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2020. Published by Science Publishing Group

Keywords

Infantile Hemangioma, Propranolol, Steroid, Involution

References
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Cite This Article
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    Mosaad Abdel Hameed Soliman, Khalid Abdel Aziz Mowafy, Mohamed Adel Abdel Maksoud, Amr Mostafa Elshafey, Nashaat Abdrabo Elsaadany, et al. (2020). The Impact of Combined Steroid-propranolol Therapy on the Involution of Infantile Hemangioma. American Journal of Pediatrics, 6(4), 397-407. https://doi.org/10.11648/j.ajp.20200604.13

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    ACS Style

    Mosaad Abdel Hameed Soliman; Khalid Abdel Aziz Mowafy; Mohamed Adel Abdel Maksoud; Amr Mostafa Elshafey; Nashaat Abdrabo Elsaadany, et al. The Impact of Combined Steroid-propranolol Therapy on the Involution of Infantile Hemangioma. Am. J. Pediatr. 2020, 6(4), 397-407. doi: 10.11648/j.ajp.20200604.13

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    AMA Style

    Mosaad Abdel Hameed Soliman, Khalid Abdel Aziz Mowafy, Mohamed Adel Abdel Maksoud, Amr Mostafa Elshafey, Nashaat Abdrabo Elsaadany, et al. The Impact of Combined Steroid-propranolol Therapy on the Involution of Infantile Hemangioma. Am J Pediatr. 2020;6(4):397-407. doi: 10.11648/j.ajp.20200604.13

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  • @article{10.11648/j.ajp.20200604.13,
      author = {Mosaad Abdel Hameed Soliman and Khalid Abdel Aziz Mowafy and Mohamed Adel Abdel Maksoud and Amr Mostafa Elshafey and Nashaat Abdrabo Elsaadany and Reem Mosaad Soliman},
      title = {The Impact of Combined Steroid-propranolol Therapy on the Involution of Infantile Hemangioma},
      journal = {American Journal of Pediatrics},
      volume = {6},
      number = {4},
      pages = {397-407},
      doi = {10.11648/j.ajp.20200604.13},
      url = {https://doi.org/10.11648/j.ajp.20200604.13},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajp.20200604.13},
      abstract = {Infantile hemangioma (IH) is the most common benign vascular neoplasm of infancy, occurring in 1.0–2.5% of white infants, especially girls. Steroids and propranolol are the most widely used drugs as a primary treatment for IH. Although their mechanism of action is not well understood, their beneficial effect is documented. Our purpose was to compare the clinical efficacy of propranolol alone and propranolol combined with steroids on the outcome of IH. A total of 450 children (median age: 9 months; range: 7 days to 3 years) were included in this randomized controlled study, being treated with combined steroid and propranolol (Group A: 230 children) compared to those treated with propranolol plus placebo (Group B: 220 children). The steroid was given as a loading dose of 2–3 mg/kg/day and then gradually tapered over 6 months, whereas propranolol was given as an incremental dose starting at 0.16 mg/kg/day and reaching a maximum of 2 mg/kg/day maintained for 18 months (duration of therapy). Frequent monitoring of the blood sugar level was mandatory in the first 2 months: electro- and echocardiograms were recorded initially but not repeated. A more rapid involution rate, recognized by color fading and flattening of the lesions, was noted in Group A compared to Group B, with the peak response reached after 10 months of therapy followed by a slower but steady rate of further improvement. No major adverse effects were observed in Group A with regard to hypoglycemia or hypotension. On the other hand, ten cases of vomiting and diarrhea, one case of fungal infection and twelve cases of somnolence and fatigue were observed in Group B. Steroid induction seems to cover the gap at initiation of therapy where propranolol cannot be given as a full dose, especially in neonates. Steroid combination minimizes the adverse effects of propranolol, namely, hypoglycemia, hypotension and bradycardia. Children treated with a combined regimen showed more effective clearing of lesions, were less likely to require surgery for residual lesions and had minimal adverse effects compared to the single-drug group. In both groups there was a faster clearing rate for the head and neck lesions than elsewhere in the body, which can be explained by the higher blood flow to this region, magnifying the level of medication to these lesions and achieving a better response.},
     year = {2020}
    }
    

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  • TY  - JOUR
    T1  - The Impact of Combined Steroid-propranolol Therapy on the Involution of Infantile Hemangioma
    AU  - Mosaad Abdel Hameed Soliman
    AU  - Khalid Abdel Aziz Mowafy
    AU  - Mohamed Adel Abdel Maksoud
    AU  - Amr Mostafa Elshafey
    AU  - Nashaat Abdrabo Elsaadany
    AU  - Reem Mosaad Soliman
    Y1  - 2020/10/17
    PY  - 2020
    N1  - https://doi.org/10.11648/j.ajp.20200604.13
    DO  - 10.11648/j.ajp.20200604.13
    T2  - American Journal of Pediatrics
    JF  - American Journal of Pediatrics
    JO  - American Journal of Pediatrics
    SP  - 397
    EP  - 407
    PB  - Science Publishing Group
    SN  - 2472-0909
    UR  - https://doi.org/10.11648/j.ajp.20200604.13
    AB  - Infantile hemangioma (IH) is the most common benign vascular neoplasm of infancy, occurring in 1.0–2.5% of white infants, especially girls. Steroids and propranolol are the most widely used drugs as a primary treatment for IH. Although their mechanism of action is not well understood, their beneficial effect is documented. Our purpose was to compare the clinical efficacy of propranolol alone and propranolol combined with steroids on the outcome of IH. A total of 450 children (median age: 9 months; range: 7 days to 3 years) were included in this randomized controlled study, being treated with combined steroid and propranolol (Group A: 230 children) compared to those treated with propranolol plus placebo (Group B: 220 children). The steroid was given as a loading dose of 2–3 mg/kg/day and then gradually tapered over 6 months, whereas propranolol was given as an incremental dose starting at 0.16 mg/kg/day and reaching a maximum of 2 mg/kg/day maintained for 18 months (duration of therapy). Frequent monitoring of the blood sugar level was mandatory in the first 2 months: electro- and echocardiograms were recorded initially but not repeated. A more rapid involution rate, recognized by color fading and flattening of the lesions, was noted in Group A compared to Group B, with the peak response reached after 10 months of therapy followed by a slower but steady rate of further improvement. No major adverse effects were observed in Group A with regard to hypoglycemia or hypotension. On the other hand, ten cases of vomiting and diarrhea, one case of fungal infection and twelve cases of somnolence and fatigue were observed in Group B. Steroid induction seems to cover the gap at initiation of therapy where propranolol cannot be given as a full dose, especially in neonates. Steroid combination minimizes the adverse effects of propranolol, namely, hypoglycemia, hypotension and bradycardia. Children treated with a combined regimen showed more effective clearing of lesions, were less likely to require surgery for residual lesions and had minimal adverse effects compared to the single-drug group. In both groups there was a faster clearing rate for the head and neck lesions than elsewhere in the body, which can be explained by the higher blood flow to this region, magnifying the level of medication to these lesions and achieving a better response.
    VL  - 6
    IS  - 4
    ER  - 

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Author Information
  • Department of Vascular Surgery, Mansoura University, Mansoura, Egypt

  • Department of Vascular Surgery, Mansoura University, Mansoura, Egypt

  • Department of Vascular Surgery, Mansoura University, Mansoura, Egypt

  • Department of Vascular Surgery, Mansoura University, Mansoura, Egypt

  • Department of Vascular Surgery, Mansoura University, Mansoura, Egypt

  • Department of Vascular Surgery, Mansoura University, Mansoura, Egypt

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