Topical timolol for the treatment of infantile hemangiomas is emerging as a safer, easier alternative to oral propranolol in selected patients, according to Dr. Sheila Fallon Friedlander.
"I think this [timolol] is something that’s very, very useful. You’re going to be seeing more of it around in use for this condition. We’ve seen encouraging results in the past 2½ years. It’s well tolerated, and I think there will come a day when even primary care physicians will be using topical timolol with comfort," she said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Topical timolol works best for small, relatively thin hemangiomas, such as eyelid lesions, advised Dr. Friedlander, president of the Society for Pediatric Dermatology and a pediatric dermatologist at the University of California, San Diego.
"You don’t put timolol on big, thick lesions and expect it to work; it won’t," she said.
At this point, the evidence base for topical timolol is far smaller than for propranolol, which has become the clear drug of choice for children requiring systemic therapy. To date, there are at least 20 articles involving about 175 timolol-treated patients, with the single largest published series consisting of 73 children (Pediatr. Dermatol. 2012;29:28-31).
Topical timolol is outpatient therapy. Used judiciously, it doesn’t appear to result in significant systemic absorption. The dose most experts recommend is 1 drop of 0.5% timolol ophthalmic gel-forming solution applied twice daily to the lesion.
Dr. Friedlander and her colleagues at Rady Children’s Hospital in San Diego are about to embark on a large, prospective study of topical timolol for infantile hemangiomas to further define the treatment efficacy; the systemic risk, if any; and appropriate patient monitoring.
Meanwhile, now that the dust has settled, propranolol is the unequivocal drug of choice when systemic therapy is warranted. It has replaced corticosteroid therapy, which is what most dermatologists were trained to use.
"Propranolol for hemangiomas is the most important thing that’s happened in pediatric dermatology in the last few years. It’s a wonderful, wonderful agent that we now have available to help us," Dr. Friedlander said.
There are more than 2,000 publications on propranolol, including a new systematic review of nearly 1,300 patients treated by dermatologists at the University of California, San Francisco, who reported a 98% response rate and a low rate of side effects (Pediatr. Dermatol. 2013 Feb. 14 [doi:10.1111/pde.12089]).
In addition, recent expert consensus guidelines on the use of propranolol for the treatment of infantile hemangiomas (Pediatrics 2013;131:128-40) are "very helpful," Dr. Friedlander continued.
Bruce Jancin/IMNG Medical Media
Dr. Sheila F. Friedlander
Today, inpatient propranolol therapy is reserved for very young infants of less than 8 weeks’ corrected gestational age, those with comorbid cardiac conditions or asthma, and kids who don’t have reliable family support. Most children are now treated as outpatients, typically beginning at about 6 months of age. The usual starting dose is 0.5 mg/kg per day, titrating up to about 2 mg/kg per day. Dr. Friedlander said she typically continues treatment for about 10 months; discontinuing too early can lead to rebound.
The recommended monitoring consists of heart rate and blood pressure measurements at baseline and 1 and 2 hours after the initial dose of propranolol, with repeat monitoring required only when the dose is increased by more than 0.5 mg/kg per day. Although routine blood glucose testing isn’t recommended, propranolol does lower the blood glucose level, so it’s essential that a treated child feeds often, and that the drug is stopped when a child has a gastrointestinal illness with vomiting or diarrhea, or is not feeding adequately for his or her age.
In addition to making sure an infant doesn’t have a cardiac condition or upper airway issues before starting the child on propranolol, check for a segmental hemangioma greater than about 5 cm on the face or neck, which is a red flag. A child with such a lesion is at risk for the PHACE syndrome and needs to undergo brain imaging to make sure the arterial vasculature is normal before propranolol therapy is started, Dr. Friedlander emphasized.
She reported having no relevant financial conflicts. SDEF and this news organization are owned by the same parent company.