What Is Infantile Hemangioma?
Infantile hemangioma (IH) is a common tumor of blood vessels affecting children. Infantile hemangioma is clinically diverse, and its appearance varies by the location, depth, and stage of progress. Infantile hemangioma may be located in any part of the body, but are more frequent in the skin of the head, face, neck, and even in the internal organs. Even though most of these lesions resolve naturally without any treatment or complication, sometimes infantile hemangioma can grow intensely and destroy tissue, impairing its function, or even risk the patient’s life.
What Are the Types of Infantile Hemangioma?
Most hemangiomas present on the top skin surface and are bright red colored and are called superficial infantile hemangiomas or “strawberry birthmarks.” Some hemangiomas present on the deep surfaces under the skin and appear either blue or skin-colored are called deep infantile hemangiomas. When a deep and a superficial skin surface are involved, they are known as mixed infantile hemangiomas.
What Is the Treatment for Infantile Hemangioma?
Treatment of infantile hemangioma includes:
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Medications like Propranolol and Timolol.
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Surgery to remove the hemangioma.
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Ligating the blood vessel to shut down the blood flow in a surgical procedure.
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Blocking the vessels from the inside using a catheter that reaches the hemangioma.
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Laser therapy for color changes in skin.
Previously, corticosteroids were the basic treatment protocol employed for complicated infantile hemangioma. However, corticosteroids have undesired side effects, such as temporary growth retardation, an increased risk of infection, and behavioral changes. Currently, Propranolol, a nonselective beta blocker, is the preferred first-line medical therapy for complicated or selected types of infantile hemangioma. Propranolol considerably reduces the need for surgery. However, despite its efficiency, the use of Propranolol in infantile hemangioma has its own risk.
What Are the Disadvantages of Using Propranolol?
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Long-term hypoglycemia in infancy has been associated with neurological morbidity.
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Bronchial hyper reactivity is a direct effect of beta 2-AR blockade.
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The lipophilic nature of Propranolol facilitates the crossing of the blood–brain barrier thereby decreasing long-term memory, psychomotor functions, sleep quality, and mood in adults.
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In children, it affects the developing central nervous system (CNS), specifically learning and memory.
To minimize many of the potential side effects of Propranolol may be the use of hydrophilic selective beta 1-blockers, such as Atenolol, which, at low dosages, have little beta 2 activity and are less likely to produce CNS related side effects.
What Is Atenolol?
Atenolol is a beta-blocker that affects the heart and the blood flow through arteries and veins. Atenolol is used to treatchest pain and high blood pressure. Atenolol is also used to lower the risk of death after a heart attack.
Why Is Atenolol Used in Infantile Hemangioma?
In recent times, the treatment of infantile hemangioma with beta-blockers has become the first choice. Moreover, Atenolol is as effective as Propranolol but associated with fewer side effects. The Propranolol acts via the renin-angiotensin system in regulating accelerated involution of proliferating infantile hemangioma by decreasing renin production in the kidneys. As the kidneys predominantly express beta-1 receptors, the renin angiotensin aldosterone system (RAAS) is most likely the missing link in understanding the working mechanism of both beta-blockers and angiotensin converting enzyme (ACE) inhibitors in the treatment of infantile hemangioma. Another explanation for the effect of Atenolol in the treatment of infantile hemangioma, besides currently unknown mechanisms, could be the limited beta-2 blocking potential of atenolol.
How Effective Is Atenolol?
Infantile hemangioma progress is abruptly stopped within four weeks of Atenolol intake when the therapy is initiated during the early proliferative phase. Patients with an ulcerated infantile hemangioma showed insufficient response after two weeks of Atenolol treatment. After oral Atenolol, complete healing of the ulcerations is seen within eight weeks of treatment. When the ulceration and pain is severe, the ulcer was excised. Patients with a segmental infantile hemangioma in the face, responded well during the initial stages of Atenolol treatment and may require surgery later. When the infantile hemangioma is treated in the early phase, immediate therapeutic effects like color changes, size reduction, softening of the texture and regression of the lesion is seen.
What Are the Safety Tolerances of Atenolol?
After the initial Atenolol treatment the heart rate decreased. Then, the heart rate gradually increased. Severe adverse effects including hypoglycemia, bronchospasm, bradycardia, and hypotension, were not documented. Diarrhea and constipation is commonly seen. Other common side effects are anxiety, transient sleep disturbance, and vomiting. These side effects subsided without requiring any further medication. Less common events included constipation and cool or mottled extremities. Several patients developed bronchiolitis and viral upper respiratory tract infection. Hemangioma ulceration, ulceration-associated pain resulted in problems with feeding, sleeping, defecation, and/or secondary infection may also be seen.
What Are the Controversies in Using Atenolol?
On the one hand, because of the young aged patients the chance that the effect was not due to the treatment but to the natural involution of the infantile hemangioma is questionable. On the other hand, a younger age may be associated with a better response to treatment. Propranolol and Atenolol have been used extensively by pediatric cardiologists for many years. However, there are still many unanswered questions for their usage in treating infantile hemangioma. It is still unknown when the Atenolol should be initiated for treating infantile hemangioma, the optimal dosage, the duration of treatment and the criteria for discontinuing treatment. It is unknown whether the long-term outcome of the treatment with beta-blockers for cosmetic indications is favorable above the natural course. There is also a lack of the possible side effects of long-term treatment of healthy children with beta-blockers.
Conclusion
Atenolol is effective in the treatment of infantile hemangioma. Atenolol seems to be less frequently associated with potentially life-threatening side effects. Further clinical studies are necessary to confirm the described effects and safety of Atenolol.
