Medical Management

Propranolol is a beta-blocker originally used to treat high blood pressure, but it is now a first-line treatment for infantile hemangiomas. Discovered in 2008 to be effective against hemangiomas, propranolol can act during both the proliferative (growth) and involution (regression) phases. Although its exact mechanism is not fully understood, it likely reduces blood vessel formation (angiogenesis), promotes cell death (apoptosis), and constricts existing blood vessels. It is administered orally and requires close monitoring to prevent side effects like low blood sugar, airway sensitivity, and sleep disturbances.

Steroids have long been used to manage hemangiomas by reducing inflammation and interfering with abnormal blood vessel growth. These can be administered systemically (by mouth) or locally (by injection into the lesion). Systemic steroids are typically used for segmental hemangiomas, while intralesional injections are better suited for focal hemangiomas. Due to potential side effects, including rebound growth and rare but serious conditions like Addisonian crisis, steroids are generally used for a limited time. The treatment duration is typically limited to three months to minimize risks.

Timolol is a topical beta-blocker similar to propranolol, commonly used as an eye drop for glaucoma. It has been repurposed to treat small, superficial hemangiomas. When applied directly to the skin, it may reduce redness and lesion size by constricting blood vessels and slowing endothelial cell proliferation. Although some systemic absorption can occur, the drug’s effect is believed to be primarily localized. For safety, only a small amount (two to three drops) should be applied at one time to avoid systemic side effects.

Vincristine is a chemotherapeutic agent used for treatment-resistant vascular tumors, particularly kaposiform hemangioendotheliomas and hemangiomatosis with liver involvement. Administered weekly via a central line, vincristine interferes with microtubule formation in rapidly dividing cells, which slows or stops tumor growth. It is often used when patients cannot tolerate steroids or when lesions do not respond adequately to other therapies. Vincristine has fewer side effects than steroids and is part of several pediatric oncology protocols.

Embolization is a minimally invasive procedure used to treat hemangiomas by blocking the blood vessels that supply the lesion. During the procedure, an interventional radiologist uses imaging guidance to inject embolic agents into targeted vessels, effectively cutting off the blood flow. This reduces the size of the hemangioma and stops its growth. Embolization is recommended when surgery is not feasible or as a pre-surgical measure to minimize bleeding risk. It helps preserve the surrounding healthy tissue while managing vascular tumors.

Sclerotherapy is a minimally invasive treatment used to shrink hemangiomas by injecting a sclerosing agent directly into the lesion or its feeding vessels. The agent irritates the vessel lining, triggering inflammation that causes the vessel to collapse and scar shut. This is especially effective for deep, complex, or treatment-resistant hemangiomas that do not respond well to oral or topical medications. Sclerotherapy can be performed on its own or as part of a combination plan and is typically guided by imaging for precise targeting.