Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic

1st line – education and reassurance

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ACUTE
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asymptomatic
1st line – 

education and reassurance

Haemangiomas generally pose no threat to function and carry minimal risk of significant cosmetic deformity.

Although most of these lesions will undergo involution, residual changes may persist in nearly one half of those afflicted, with persistent scarring, skin atrophy and redundancy, discoloration, and telangiectasia.

A useful social defence for patients particularly sensitive to comment about visible haemangiomas is to turn the conversation to the euphemistic term 'birthmark' or 'beauty mark'.

with functional impairment or cosmetic disfigurement

1st line – beta-blocker and/or corticosteroid

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ACUTE
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with functional impairment or cosmetic disfigurement
1st line – 

beta-blocker and/or corticosteroid

Propranolol is the systemic treatment of choice for infantile haemangiomas.[41] Efficacy has been demonstrated in haemangiomas in functionally or cosmetically important locations,​ in airway haemangiomas, in ulcerated haemangiomas, and in visceral haemangiomas.[45][46][47][48][49][50]

Rebound growth has been noted after cessation of therapy, so treatment is often continued through to the time of theoretical involution, or around 12 months.[51]

Absolute contraindications to propranolol include certain conduction defects such as sick sinus syndrome or 2nd or 3rd degree atrioventricular (AV) block. Relative contraindications include impaired cardiac function, sinus bradycardia, hypotension, 1st degree AV block, asthma or bronchial hyper-reactivity, diabetes mellitus, and chronic renal insufficiency.[52] Propranolol should be used cautiously in the setting of PHACES syndrome because propranolol-induced hypotension could theoretically compromise already tenuous cerebral perfusion.[54]

Systemic corticosteroids are still occasionally used instead of beta-blockers for infantile haemangiomas.[58]​ Depending on the response and the age of the patient, anticipated duration of therapy may continue from 6 to 12 months.

Systemic corticosteroids can also be used as an adjunctive treatment to a beta-blocker.[58] Again, anticipated duration of therapy may be from 6 to 12 months.

Rebound growth of haemangiomas has been well documented while tapering oral corticosteroids, so close clinical follow-up is required.[2][16][59][60]

Topical beta-blockers may be helpful in the treatment of superficial infantile haemangiomas.[55][56] This treatment can be considered when systemic treatment is not warranted or is contraindicated.

If the haemangioma is well localised without deep extension, intralesional corticosteroids represent an additional treatment option. In general, intralesional treatments are spaced about 1 month apart. A range of corticosteroids has been used, although triamcinolone is a typical agent.[63] The systemic adverse effects of oral corticosteroids are avoided in most cases.[64][65]

Primary options

propranolol: 2-3 mg/kg/day orally given in 2-3 divided doses

OR

timolol ophthalmic: (0.5% gel) apply thin layer to lesion twice daily

Secondary options

prednisolone: 2-5 mg/kg/day orally

OR

triamcinolone acetonide: consult specialist for guidance on intra-lesional dose

Consider – surgical excision

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ACUTE
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with functional impairment or cosmetic disfigurement
Consider – 

surgical excision

Additional treatment recommended for SOME patients in selected patient group

Whether and when to excise an infantile haemangioma is decided after weighing the risk of waiting versus the benefit of immediate excision. If conservative treatment has been inadequate, a child with a proliferative infantile haemangioma that threatens functional and cosmetic integrity is a good candidate.

Excision may also be necessary in the setting of ulceration or bleeding. The nature of some infantile haemangiomas causes them to lend themselves to easy surgical intervention: for example, small pedunculated lesions with a narrow base that would leave minimal scar after excision.[2]

Surgery is more often used to improve cosmetic appearance after involution is complete. For example, a child entering school with redundant, unsightly fibro-fatty tissue is a good candidate for surgical intervention.

Inappropriate surgical intervention can increase the morbidity of infantile haemangiomas.[67]

Plus – astringents and barrier protection

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ACUTE
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with functional impairment or cosmetic disfigurement
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with ulceration
Plus – 

astringents and barrier protection

Treatment recommended for ALL patients in selected patient group

Burow's solution compresses applied once or twice daily may be used for gentle debridement.

Petrolatum-impregnated gauze is helpful for discomfort from lesions in the perineal area and may be applied when required.

Consider – topical antibiotic

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ACUTE
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with functional impairment or cosmetic disfigurement
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with ulceration
Consider – 

topical antibiotic

Additional treatment recommended for SOME patients in selected patient group

Topical antibiotics, including mupirocin and metronidazole, may be applied under a thin hydrocolloid dressing to prevent colonisation of abrasions. Treatment can be continued until improvement is seen, although there are no good studies supporting this recommendation. Clinical judgement should be used.

Oral antibiotics should be given if secondary infection is present.

Primary options

metronidazole topical: (0.75%) apply to the affected area(s) twice daily

Secondary options

mupirocin topical: (2%) apply to the affected area(s) three times daily

Consider – beta-blocker if not previously treated

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ACUTE
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with functional impairment or cosmetic disfigurement
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with ulceration
Consider – 

beta-blocker if not previously treated

Additional treatment recommended for SOME patients in selected patient group

Many clinicians will institute treatment with either a topical or systemic beta-blocker at the time of ulceration if the lesion has not been previously treated with a beta-blocker.

Primary options

propranolol: 2-3 mg/kg/day orally given in 2-3 divided doses

OR

timolol: (0.5% gel) apply thin layer to lesion twice daily

Consider – topical becaplermin

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ACUTE
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with functional impairment or cosmetic disfigurement
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with ulceration
Consider – 

topical becaplermin

Additional treatment recommended for SOME patients in selected patient group

Becaplermin, a recombinant human platelet-derived growth factor, promotes wound repair, cell proliferation, and granulation tissue formation. Treatment can be continued until improvement is seen, although there are no good studies supporting this recommendation. Clinical judgement should be used.

Primary options

becaplermin topical: (0.01%) apply to the affected area(s) once daily

Consider – analgesia

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ACUTE
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with functional impairment or cosmetic disfigurement
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with ulceration
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Mild analgesics, such as oral paracetamol or topical lidocaine, may be used for pain relief.

Primary options

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

lidocaine topical: (3% cream) apply to the affected area(s) two to three times daily when required

More

Consider – pulsed dye laser

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ACUTE
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with functional impairment or cosmetic disfigurement
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with ulceration
Consider – 

pulsed dye laser

Additional treatment recommended for SOME patients in selected patient group

The pulsed dye laser is an effective for treatment of ulcerated haemangiomas, and for post-involution telangiectasias.[13][69][70] It is used less often as a primary treatment for haemangiomas.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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