Diagnosis and Management of Infantile Hemangioma

Oral Propranolol Versus Other Beta-blockers or Dosage Forms
Three small studies compared propranolol with nadolol 101 or atenolol, 102,146,147 and one study
evaluated oral, intralesional, and topical propranolol. 93 Atenolol and nadolol demonstrated
promising effects on lesion size (no significant differences in effectiveness of propranolol and
atenolol and greater effectiveness in a small study comparing nadolol and propranolol) and low
levels of adverse effects, which may suggest that improvements can be achieved in the
propranolol safety profile. More children receiving oral propranolol had an excellent or good
level of resolution than those receiving topical or intralesional (n=11/15, 8/15, 5/15,
respectively), but the difference among groups was not significant. 93
In head-to-head comparisons, there were no significant differences in response between
propranolol and atenolol in two studies and better response to nadolol versus propranolol in one
small study. We considered the SOE as low for no difference in response with propranolol,
nadolol, or atenolol (systemic beta-blockers).
Timolol Versus Placebo/Observation or Other Active Modality
Six comparative studies addressed timolol (two RCTs 14,104 and four cohort
studies 103,105,106,144 ). All studies included children with superficial IH, and two (one comparing
timolol with observation and one comparing timolol and laser) also included children with mixed
(superficial and deep) IH. 14,144 Timolol was significantly more effective than observation or
placebo in three studies, 103,104,144 and one study comparing imiquimod with timolol did not
demonstrate that one intervention was more effective than the other. 105 In one study comparing
timolol and PDL+Nd:YAG laser, timolol was associated with greater improvements in
superficial lesions, while laser was associated with greater improvements in mixed (superficial
and deep) lesions. 106 In another comparing timolol alone with timolol plus PDL, mean global
assessment scores were more improved in the combination arm than in the timolol arm, though
IH in 97 percent of children in both arms improved from baseline. 14 No harms of timolol were
observed in any study.
In network meta-analysis, the mean expected clearance rate for topical timolol was 62
percent (95% BCI: 39% to 83%) relative to 6 percent (95% BCI: 1% to 11%) for placebo or
observation arms. We considered SOE as low for the effectiveness of timolol compared with
placebo or observation.
Harms of Beta-blockers
In addition to these comparative studies, a total of 56 case series addressed harms of betablockers
for IH. 16,18,151-205 We assessed four case series as good quality for harms
reporting, 168,171,181,186 one as fair quality, 182 and 51 as poor quality. 16,18,151-167,169,170,172-180,183-185,187-
205
Twenty-four comparative studies also reported harms data, and we assessed four as good
quality for harms reporting 92,98,104,105 and the remainder as poor quality for harms
reporting. 14,17,93-97,99-103,106,130-133,144-147,150 Harms most frequently reported with use of oral betablockers
(propranolol, atenolol, nadolol) included sleep disturbances, cold extremities,
gastrointestinal symptoms, bronchial irritation (classified as hyperreactivity, bronchospasm,
bronchiolitis, cold induced wheezing), and decreases in blood pressure or heart rate. Rates of
significant clinically important harms ranged from 0 to 100 percent across studies of propranolol
and from 1 percent to 50 percent for minor harms. We considered SOE as moderate for the
association of propranolol with these harms. Data were insufficient to comment on harms in
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