What are the treatment options for hemangiomas in children (infantile hemangiomas)?

Treatment is recommended in about 10 to 15 out of 100 children, usually because

• the hemangioma is in a difficult place like the eye, nose, lip or ear, which can make it harder to see, breathe, eat or hear,
• the hemangioma is large and spread out (segmental hemangioma) or very noticeable, or
• it causes things like sores (ulcers) or an underactive thyroid.

Getting treatment soon enough can prevent other health problems and complications caused by the hemangioma. It is best if the treatment is started when the baby is 1 to 5 months old because then the growth of the hemangioma can be stopped.

Doctors usually prescribe medication called propranolol (a beta blocker). Beta blockers are normally used to lower blood pressure. But they can also stop the development and growth of hemangioma cells. The hemangioma then goes away after a few months.

Children are given the medication twice a day as a syrup. The treatment lasts at least six months, but often until their first birthday or sometimes longer. The doctor will adjust the dose to the child’s body weight every four weeks.

The treatment usually takes place in an outpatient setting. But it can also be started in a hospital, to keep a close eye on possible side effects. That is mainly recommended for children who have birth defects or certain diseases affecting their heart or lungs, and for children who are less than eight weeks old. In premature babies, these weeks are counted from their due date, not their actual date of birth.

Propranolol is very effective: Many hemangiomas go away when treated with it. A study that compared this medication with a placebo (fake drug) found that the hemangiomas had almost or completely disappeared after six months in

• about 4 out of 100 children who took a placebo, and
• about 60 out of 100 children who took propranolol.

Propranolol also seems to stop hemangiomas from growing any further (or at least make them partially go away again) in most children.

Sometimes hemangiomas come back again after successful treatment (in about 10 to 25 out of 100 children). But then they're often less noticeable and don’t have to be treated again. Hemangiomas on the surface of the skin are less likely to return. Longer treatment, such as for one year rather than 6 months, also reduces the risk of hemangiomas returning. For this reason, parents are usually advised to give their child the medication up until their first birthday.

Most children tolerate propranolol well. One possible (but rare) side effect is low blood pressure. To be on the safe side, the child’s blood pressure is monitored in the doctor’s office or hospital for two hours after first taking propranolol.

Low blood sugar is another rare side effect. Parents are told how to spot possible signs of low blood sugar and how to react properly. These signs include pale skin, unusual tiredness and cold sweats. Taking the medication during or shortly after a meal can reduce the risk of this side effect. The propranolol dose should be skipped if the child isn’t eating properly, vomits or has diarrhea.

In rare cases, propranolol also causes sleep problems or respiratory issues. In very rare cases, the muscles around the airways seize up (bronchospasm) shortly after taking propranolol. The child then has difficulty breathing. That is an emergency that needs to be treated quickly.

There is a debate among experts about whether propranolol might affect children's psychological or mental development. But there is currently no scientific evidence that it has this effect.

Propranolol is usually not an option for:

• Premature babies under the age of five weeks (counting from the due date, not the actual date of birth)
• Children who are breastfed and whose mothers take medication that can't be used together with propranolol
• Children with certain health problems – including asthma, bronchospasm, low blood sugar levels and certain cardiovascular (heart and blood vessel) diseases

If the doctor suspects that your child might have a cardiovascular disease (perhaps because close relatives do), an ECG or ultrasound scan of the heart will be done first.

Propranolol is approved for use starting between the ages of 5 weeks and 5 months. If treatment is to be started in children who are younger or older than that, the doctor first has to give parents detailed information about the possible risks and effects associated with this treatment (off-label use).

No other beta blockers are currently approved for the treatment of hemangiomas (in Germany). But studies suggest that a beta blocker called atenolol is similarly effective at treating hemangiomas. It also seems to be very well tolerated, but more research is needed to be sure. After getting the information they need from the doctor, parents can decide to treat their child's hemangioma with atenolol "off label." But that only happens very rarely – for example, because a child isn’t able to take propranolol due to another medical condition they have.

Hemangiomas on the surface of the skin can also be treated with lotions, creams or gels that contain beta blockers. This treatment hasn't been approved yet, either, and there are only a few reliable studies on how well it works. What's more, it can cause side effects such as low blood pressure or a slower heartbeat: When medication is applied directly to skin, it can still enter the bloodstream – for instance, if it gets into the mouth or nose.

Laser treatment is sometimes also offered. For hemangiomas on the surface of the skin, this involves ablating (destroying) the blood vessel growths with a pulsed dye laser (PDL) or intense pulsed light (IPL), for example. The area of skin is numbed with a local anesthetic first. Hemangiomas that are deeper in the skin are usually treated with a special type of laser called an Nd:YAG laser. That has to be done under general anesthesia. The treatment is normally repeated several times.

It is currently not clear how well laser therapy works in the treatment of hemangiomas. It can also have side effects. For instance, the skin in the treated area may become thinner or lighter in color. This is probably more common in dark skin. For this reason, experts only recommend laser therapy if a child can’t use beta blockers or this medication isn't effective enough.

Other treatments are only used very rarely. There are no good studies on their pros and cons:

• Cryotherapy (cold therapy): This "freezing" treatment is used to treat small hemangiomas on the surface of the skin. It can leave light patches on the skin and (less commonly) scars from the extremely low temperatures. Because of this, cryotherapy isn't really suitable – particularly on very visible parts of the body.
• Embolization: This involves inserting a catheter into the affected blood vessels and, for example, injecting a tissue adhesive into them to close them off. Tissue adhesives make the blood vessel tissue stick together. Young children are given a general anesthetic for this procedure.

Surgery to remove hemangiomas (partially or fully) is only considered in rare cases where they are life-threatening or can’t be treated in any other way – like hemangiomas on the nose or throat that make it harder to breathe.

In the past, it was common to treat hemangiomas with steroid medications (glucocorticoids). Experts no longer recommend using them, though, because propranolol has fewer side effects. Nowadays steroids are only used in rare, life-threatening situations, in addition to propranolol.

After going away, hemangiomas may leave behind darker areas of discolored skin, blood vessels that can be seen through the skin, or other abnormal areas. They can be treated afterwards with a laser under local anesthetic. If deeper layers of skin are affected, an Nd:YAG laser can be used under general anesthetic.

Scars or loose skin can be treated by a skin specialist (dermatologist). Surgery is only needed in very rare cases – perhaps because the hemangioma prevented a part of the body (like the nose) from developing normally. That can then be corrected using plastic surgery, for example. Or by other specialists, depending on the part of the body affected. These kinds of procedures shouldn't be done in children under the age of four, though.

It is not advisable to treat hemangiomas yourself – for example, with home remedies like apple cider vinegar or castor oil. There is no scientific proof that they work. And they can damage the skin.

By no means should you scratch open or pierce a hemangioma. This could make it bleed a lot and become infected. It won't make the hemangioma go away, either.