184 Case Reports
Successful treatment of a large
hemangioma with propranolol
Waseem Mousa1, Kirsten Kues1, Ellen Haas1, Peter Lauerer2,
Helena Pavlakovic2, Michael P. Schön1, Markus Zutt1
(1) Department of Dermatology, Venereology and Allergology, Georg August
University Göttingen, Germany
(2) Department of Pediatric Medicine I, Georg August University Göttingen,
Germany
JDDG; 2010 • 8:184–186 Submitted: 21. 7. 2009 | Accepted: 4. 8. 2009
Summary
Hemangiomas are the most common
vascular tumors in children. They occur
in 8–12 % of all infants and in 22 % of
premature infants (female: male = 3: 1).
Hemangiomas are usually sporadic;
their etiology is unknown [1].
A premature female infant, born at 28
weeks of gestation, presented with a
large hemangioma of the right tho-
racic wall. Within the first few weeks,
the hemangioma showed rapid hori-
zontal and vertical growth as well as
ulceration, which led us to initiate
systemic therapy.
The effectiveness of propranolol
(non-selective ß-blocker) in the man-
agement of severe cases of heman-
gioma has been shown in a recent
series of cases [2]. We began oral pro-
pranolol treatment, in close interdisci-
plinary cooperation. After a few days of
therapy, the tumor had stopped
expanding. After 18 weeks, there has
been marked regression but the thera-
py is still being continued. We propose
that propranolol may be an effective
and relatively well tolerable alternative
in the management of selected cases
of severe hemangiomas in infancy,
providing interdisciplinary coopera-
tion between dermatologists and
pediatricians is available.
Keywords
emangioma – propranolol –
beta-blocker
JDDG | 3 ˙2010 (Band 8)
DOI: 10.1111/j.1610-0387.2009.07266.
Introduction
Hemanigiomas of infancy often have a
self-limiting course, but treatment may
be necessary if complications arise due to
the affected site, growth of the lesion, or
other factors. The goal of any therapy is
to stop the growth of the lesion and
bring about regression.
Case report
We report on a premature infant girl
who was delivered in the 28th week (+2
days) of pregnancy. The baby measured
32 cm and weighed 740 g. At birth she
had a 3 ⫻ 4 cm large, raised, sharply-
bordered bright red tumor on the right
wall of the thorax. A clinical diagnosis
was made of a cutaneous/subcutaneous
infantile hemangioma (Figure 1). Regular
clinical examinations were performed
and the size of the rapidly growing tu-
mor was documented. By the eighth
week of life, the hemangioma grown to
6.6 ⫻ 8.8 cm. Imaging studies were or-
dered to assess the depth of the heman-
gioma and to rule out deeper sources
(e.g., an arteriovenous shunt) and in-
volvement of internal organs. Color-
coded duplex ultrasound showed a depth
of up to > 2 cm with extensive superficial
and deep vascularizations (Figure 2).
Magnetic resonance imaging (MRI)
showed involvement of the back muscles
as well as intrathoracic components of
the hemangioma (Figure 2) and a small
hemangioma measuring about 3 cm in
diameter in the liver. During the first few
weeks of life, the tumor rapidly grew in
size and thickness. The mother reported
© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin • JDDG • 1610-0379/2010/0803
traces of blood on the infant’s clothing,
suggesting rapid growth and pressure.
The lesion developed central ulcerations
which steadily increased in size. Given
the strong tendency toward growth and
the deep components of the tumor, we
chose to initiate systemic therapy after
consultation with pediatrics.
Off-label systemic therapy was begun
with oral propranolol (initial dose of
1 mg /kg of body weight) after discus-
sion with the parents who gave written
consent. On the second day the dose was
increased to 2 mg/kg body weight, which
is well below that given for cardiac indi-
cations. Treatment was performed on an
inpatient basis with monitoring of heart
rate, blood pressure, electrolyte and
blood glucose levels; ECG and echocar-
diography were also performed. Therapy
was well tolerated. Two complications
occurred, but were readily manageable.
Initial hypotension of 60/35 mmHg was
treated with i.v. volume substitution and
did not recur. Hyperkalemia with values
of up to 6.1 mmol/l (norm =
3.7–5.7 mmol/l) appeared after 4 days of
therapy and was first treated with
furosemide 1.5 mg/kg of body weight
i.v., and later with oral furosemide
1 mg/kg of body weight as well as salbu-
tamol inhalation. The patient’s status re-
turned to normal and accompanying
medication was discontinued. A superin-
fection of the ulcerated hemangioma was
treated with intravenous antibiotics.
The hemangioma responded quickly to
therapy and stopped growing in size and
thickness. After a few days the tumor be-
came flatter and decreased in diameter.
The ulcerations also healed and there
were areas of regression (Figure 1). Out-
patient treatment with given 8 weeks of
oral propranolol2 mg/kg/KG 18 weeks
ambulant on an outpatient basis was well
tolerated. A follow-up duplex ultrasound
after 6 weeks showed a significant de-
crease in penetration depth and vascular-
ization (Figure 2). A follow-up MRI is
planned.
Discussion
Given rapid progression and potential
complications of a large hemangioma of
infancy, quick and sufficient therapy is
needed. In our patient, laser (e.g.,
ND:YAG laser along with pulsed dye
laser) and cryotherapy were ruled out
due to the diameter and depth of the
lesion Systemic therapy was chosen in

Figure 1: Clinical course. Picture above left side shows 8 week old patient before therapy, the other photos show the interval from start of therapy.
Figure 2: MRI with intrathoracic hemangioma (a); Duplex ultrasound before therapy (b); Duplex
ultrasound after 7 weeks of therapy (c), green lines show the depth.
accordance with current guideline rec-
ommendations [1]. The goal of systemic
therapy is to stop the expansion of the
hemangioma by stopping growth and if
possible to induce regression. Pulse ther-
apy is generally with prednisolone
(2–5 mg/kg body weight daily). Vin-
cristine or cyclophosphamide are also oc-
casionally used [1].
Recent studies have shown the effective-
ness of propranolol (a non-selective beta
© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin • JDDG • 1610-0379/2010/0803
blocker) in large hemangiomas [2].
There are probably various factors re-
lated to the mechanism of action of pro-
pranolol that make it successful in the
treatment of large hemangiomas: propra-
nolol causes vasoconstriction and thus
possible occlusion of superficial, and es-
pecially deep supplying blood vessels.
Within a relatively short time after start-
ing therapy, the hemangioma begins to
lighten. Also under discussion are down-
Case Reports 185
regulation of the Raf mitogen-activated
protein kinase signaling pathway with
reduced expression of vascular endothe-
lial growth factor (VEGF) and basic fi-
broblast growth factor (bFGF). VEGF
and bFGF are important angiogenic fac-
tors during the growth phase of heman-
giomas. Propranolol is also thought to
cause direct induction of apoptosis in
capillary endothelial cells [2]. Standard
recommendations on the length of ther-
apy with propranolol are still lacking.
Treatment regimens of 4–6 months have
been reported [3]. This question should
also be addressed in future randomized
studies. Presumably, therapy should be
continued until growth of the lesion has
been stopped. If after discontinuing pro-
pranolol therapy superficial heman-
gioma components remain, these can be
readily removed with combined laser
therapy. The patient should be ade-
quately monitored for any adverse effects
which must be treated promptly if they
occur, as in the patient described here.
To summarize, propranolol is an
effective treatment option with rela-
tively few side effects for large and
deep hemangiomas or for heman-
giomatosis. In infants, therapy can be
initiated and carried out under the co-
operation of the treating pediatrician
and dermatologist. <<<
Conflict of interest
None.
JDDG | 3 ˙2010 (Band 8)
186 Case Reports
Correspondence to
Dr. med. Markus Zutt
Abteilung Dermatologie, Venerologie
und Allergologie
der Universitätsmedizin Göttingen
Von-Siebold-Straße 3
D-37075 Göttingen
Tel.: +49-551-39-6410
Fax: +49-551-39-12811
E-mail: mzutt@gwdg.de
JDDG | 3 ˙2010 (Band 8)
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1 Hohenleutner U, Landthaler M, rung und Therapie-Empfehlungen.
Hamm H, Sebastian G. Hämangiome pädiatrie hautnah 2009; 2: 133–46.
im Säuglings- und Kindesalter. J Dtsch
Dermatol Ges 2007; 4: 334–9.
2 Letaute-Labreze C, Dumas de la
Roque E, Hubiche T, Boralive F,
Thambo J-B, Taieb A. Propranolol
for severe hemangiomas of infancy.
N Engl J Med 2008; 358: 2649–
51.
© The Authors • Journal compilation © Blackwell Verlag GmbH, Berlin • JDDG • 1610-0379/2010/0803
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