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

Hemangiomas 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 defense for patients who are particularly sensitive to comment about visible hemangiomas 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 hemangiomas.[42] Efficacy has been demonstrated in hemangiomas in functionally or cosmetically important locations,​ in airway hemangiomas, in ulcerated hemangiomas, and in visceral hemangiomas.[46][47][48][49][50][51]

Rebound growth has been noted after cessation of therapy, so treatment is often continued through the time of theoretical involution, or around 12 months.[52]

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 hyperreactivity, diabetes mellitus, and chronic renal insufficiency.[53] Propranolol should be used cautiously in the setting of PHACES syndrome because propranolol-induced hypotension could theoretically compromise already tenuous cerebral perfusion.[55]

Systemic corticosteroids are still occasionally used instead of beta-blockers for infantile hemangiomas.[59]​ 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.[59] Again, anticipated duration of therapy may be from 6 to 12 months.

Rebound growth of hemangiomas has been well documented while tapering oral corticosteroids, so close clinical follow-up is required.[2][16][60][61]

Topical beta-blockers may be helpful in the treatment of superficial infantile hemangiomas.[56][57] This treatment can be considered when systemic treatment is not warranted or is contraindicated.

If the hemangioma is well localized without deep extension, intralesional corticosteroids represent an additional treatment option. In general, intralesional treatments are spaced about 1 month apart. A range of corticosteroids have been used, although triamcinolone is a typical agent.[64] The systemic adverse effects of oral corticosteroids are avoided in most cases.[65][66]

Primary options

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

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OR

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

Secondary options

prednisone: 2-5 mg/kg/day orally

OR

triamcinolone acetonide: consult specialist for guidance on intralesional dose

Consider – surgical excision

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ACUTE
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with functional impairment or cosmetic disfigurement
Consider – 

surgical excision

Treatment recommended for SOME patients in selected patient group

Whether and when to excise an infantile hemangioma 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 hemangioma 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 hemangiomas 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 hemangiomas.[68]

Plus – astringents and barrier protection

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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 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

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 colonization of abrasions. Treatment can be continued until improvement is seen, although there are no good studies supporting this recommendation. Clinical judgment 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

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

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OR

timolol ophthalmic: (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

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 judgment 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

Treatment recommended for SOME patients in selected patient group

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

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

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

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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

Treatment recommended for SOME patients in selected patient group

The pulsed dye laser is an effective for treatment of ulcerated hemangiomas, and for post-involution telangiectasias.[13][70][71] It is used less often as a primary treatment for hemangiomas.

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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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